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(770) 464-1900
227 Brookstone Place, Social Circle, GA 30025
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New Patient Registration

Please note that it is important to fill in all the fields before submitting. Thank you.
About you
Title : MrMrsMsDr
*Name :
 *Last name

 Mid name
 *First name
I prefer to be called : Sex : MaleFemale
*Your birthday :
Age:
*Home address :
City
State
Zip
 APT#
*Email address :
Social security# :
Marital Status :
Single Married Partnered Divorced/Separated
Widowed
*Telephone Home : ()--
Cell phone# : ()--
Telephone Work: ()---
Driver’s license# :
Employer :
Employer address :
CityState
Zip
 APT#
How long there ? Occupation :

Where & when are best times to reach you?
How did you hear about us?
Whom may we Thank for referring you?
Other family members seen by us :
Previous dentist :
Present dentist :
Person responsible for account :

Spouse information
His / Her name : Employer :
Birthday :
Social security# :
Driver’s license# :
Telephone work : ()---

Relative or friend not living with you
His / Her Name : Relationship :
Telephone Home : ()--
Telephone Work : ()---

Medical History
Do you have a personal physician? Yes No
Physician’s Name :
Telephone home #: ()--
Date of last visit :
Your current physical health is : Good Fair Poor
Are you currently under the care of a physician? Yes No
Do you smoke or use tobacco in any other form? Yes No
Have you had any metal rods, pins or implants? Yes No
Are you taking any prescription / Over-the-counter drugs? Yes No
Have you ever taken Fosamax, or any other bisphosphonate? Yes No
Do you wear a cardiac pacemaker, or have you had heart surgery?Yes No
Are you required to take any medication before your dental visit?Yes No
For women :
Are you using a prescribed method of birth control? Yes No
Are you pregnant? Yes No                Week # :
Are you nursing? Yes No
Have you ever had any of the following diseases or medical problems
Yes No   Abnormal Bleeding / Hemophilia
Yes No    Artificial bones / Joints / Valves
Yes No   Chemotherapy (Center, leukemia)
Yes No    AIDS related complex
Yes No    Alcohol / Drug abuse
Yes No    Anemia
Yes No    Arthritis
Yes No   Asthma
Yes No   Blood transfusion
Yes No   Colitis
Yes No    Congenital heart defect
Yes No   Diabetes
Yes No    Difficulty breathing
Yes No    Emphysema
Yes No    Epilepsy / seizures
Yes No    Excessive bleeding
Yes No    Respiratory disease
Yes No    Artifical prosthesis
Yes No    Congenital heart disease
Yes No    X-Ray or cobalt treatment
Yes No    Fainting spells / seizures
Yes No    Frequent headaches
Yes No    Rheumatic / Scarlet fever
Yes No    Sickle cell disease / Traits
Yes No    Heart attack / Surgery
Yes No    Heart murmur
Yes No    Hepatitis / jaundice
Yes No    Herpes / Fever blisters
Yes No    High blood pressure
Yes No    Hospitalized for any reason
Yes No    Allergies or Hives
Yes No    Kidney disease
Yes No    Liver disease
Yes No    Low blood pressure
Yes No    Lupus
Yes No    Angina pectoris
Yes No    Cerebral palsy
Yes No    Joint replacement
Yes No    Nervous disorder
Yes No    Tumors or growths
Yes No    Mitral valve prolapse
Yes No    Pacemaker
Yes No    Psychiatric treatment
Yes No    Radiation treatment
Yes No    Glaucoma
Yes No    Shingles
Yes No    Hay fever
Yes No    Sinus problems
Yes No    Stroke
Yes No    Thyroid problems
Yes No    Tuberculosis (TB)
Yes No    Ulcers
Yes No    Venereal disease
Yes No   Tonsillitis
Yes No   Head injuries
Yes No   Heart failure
Yes No   Chicken pox
Yes No   SinusTrouble
Yes No   Blood disease
Yes No   Drug addiction
Please list any serious medical condition(s) that you have ever had :

Are you allergic to any of the following?
Yes No   Aspirin
Yes No   Penicillin
Yes No   Jewelry / Metals
Yes No   Anesthetic (Novocain, ETC)
Yes No   Dental anesthetics
Yes No   Other
Yes No   Erythromycin
Yes No   Sulfa Drugs
Yes No   Codeine
Yes No   Tetracycline
Yes No   Latex
Please list any other drugs / Materials that you are allergic to :

Insurance information
Primary insurance
Dental coverage? Yes No
Insurance Co. name:
Address :
City State
Zip
Phone : ()--
Group# (Plan, Local or Policy#):
Insured’s name :
Relationship :
Birthday :
SSN :
Insured’s employer :
Address :
City State
Zip
Secondary insurance
Dental coverage? Yes No
Insurance Co. name :
Address :
City State
Zip
Phone : ()--
Group# (Plan, Local or Policy#):
Insured’s name :
Relationship :
Birthday :
SSN :
Insured’s employer :
Address :
City State
Zip

Dental history
Why have you come to the dentist today?
Are you currently in pain? Yes No
Do you require antibiotics before dental treatment? Yes No
Your current dental health is : Good Fair Poor
Have you ever had a serious/difficult problem associated with any previous dental work? Yes No
Do you floss daily? Yes No
Brush daily? Yes No
Type of bristles on your toothbrush? Hard Medium Soft
Have you ever had gum treatment? Yes No
Do your gums ever bleed? Yes No
Ever Itch? Yes No
Have you ever had periodontal disease? Yes No
Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ/TMD)? Yes No
Are your teeth sensitive to Heat Cold
anything else?
Do you have any loose teeth? Yes No
Do you still have wisdom teeth? Yes No
Would you like fresher breath? Yes No
Whiter teeth? Yes No
Are you happy with the way your smile looks? Yes No
If not, what would you change?
* The information and health history and preceding answers are true and correct to the best of my knowledge. I authorize and give consent to perform dental services agreed between doctor and patient and/or guardian to be necessary or advisable, including the use of local anesthesia and other medications as indicated. I agree that, regardless of insurance coverage, I am responsible for payment for services rendered. If I ever have any changes in my health or if my medication change I will, without fail, inform the doctor at my next appointment.
*Signature :
Date :
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Social Circle Dental Located at 227 Brookstone Place, Social Circle, GA 30025
Phone: (770) 464-1900.
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