New Patients Registration Form

Please note that it is important to fill in all the fields before submitting. Thank you.
About you
Title : Mr Mrs Ms Dr
Patient Name :
*Last Name :
Middle Name : *First Name :
prefer to be called : Sex : Male Female
*Your birthday :
Age:
*Home Address
City :
State :
Zip :
Apt# :
*Email address :
Social security# :
Marital Status : Single Married Partnered Divorced/Separated Widowed
*Home Phone : ()--
Work Phone: ()---
Cell Phone# : ()--
Driver’s license# :
Employer :
Employer Address City :
State : Zip :
Apt# :
Occupation : How long there ?
College Student? Yes No If Yes, What College? 
Previous dentist : Present dentist :
Where & when are best times to reach you?
How did you hear about us?
Have you visited our website? Yes No
Whom may we Thank for referring you?
Other family members seen by us :
Person responsible for account :
Spouse Information
His/Her Name : Birthday:
Driver’s license# : SSN :
Employer : Work Phone: ()---
Relative or friend not living with you
His/Her Name : Home Phone: ()--
Relationship : Work Phone: ()---
Insurance Information
Primary Insurance -
Dental coverage? Yes No
Insurance Co.: Phone No: ()--
Address : City :
State : Zip :
Group# (Plan, Local or Policy#):
Insured’s name : Birthday :
Relationship : SSN :
Insured’s Employer :
Address : City :
State : Zip :
Secondary Insurance -
Dental coverage? Yes No
Insurance Co.: Phone No: ()--
Address : City :
State : Zip :
Group# (Plan, Local or Policy#):
Insured’s name : Birthday :
Relationship : SSN :
Insured’s Employer :
Address : City :
State : Zip :
Medical History
Do you have a personal physician? Yes No
Physician’s Name : Phone No: ()--
Date of last visit :
Your current physical health is : Good Fair Poor
Are you currently under the care of a physician? Yes No
Please explain :
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
Please explain :
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
When?
Are you required to take any medication before your dental visit? Yes No
What?
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 Congenital heart disease Yes No Artificial bones / Joints / Valves
Yes No Fainting spells / seizures Yes No Abnormal Bleeding / Hemophilia
Yes No X-Ray or cobalt treatment Yes No Chemotherapy (Center, leukemia)
Yes No Hospitalized for any reason Yes No Sickle cell disease / Traits
Yes No Rheumatic / Scarlet fever Yes No Heart attack / Surgery
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 Artificial prosthesis Yes No Frequent headaches
Yes No Glaucoma Yes No Hay fever
Yes No Heart murmur Yes No Hepatitis / jaundice
Yes No Herpes / Fever blisters Yes No High blood pressure
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 Shingles 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 :
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
Kennesaw Marietta Cosmetic Dentist - Rate A Biz Reviews Kennesaw Marietta Cosmetic Dentist - Dental Videos
5 Star
  • Thirty-Two Dental
    Rating : 5 Kennesaw Marietta Cosmetic Dentist - 5 Star Reviews 1


    Dr. Vo and Dr. Breckly are absolutely fantastic! Never worry about another painful trip to the dentist if you are going to see them. They make sure you are never in any pain throughout the entire procedure. I just had my wisdom teeth removed and Dr. Vo did a fabulous job, as always. I had four impacted wisdom teeth and they were out before I knew it. I was up and eating solid food the very same day, and could have been back at work if I needed to. My stitches fell out within a few days and everything healed up much faster than any of my friends who saw other doctors. I stayed awake for the procedure, and I would say that it definitely is much better than being put to sleep. It has a faster heal time and less discomfort. My face honestly didn't even swell. I've gone to Dr. Vo and Breckly for minor things before and they have always been amazing, but after my great experience with something more major, I know they are by far the two of the best dentists, I have ever seen.
  • Rating: 5 Kennesaw Marietta Cosmetic Dentist - 5 Star Reviews 2
    Dr. Vo and Dr. Berkley are the ONLY dentists we see. Dr. Vos taken care of my parents, my husband, our daughter and son, and myself for the past 7 years. We love the care and the personal relationship she establishes with her patients. She takes the time to get to know us, our families, our dental concerns, which is NOT the usual in the business.Thank you for everything. Dr. Berkley is very attentive and gently with my children. We came in for a cleaning yesterday and they did great under his medical care. The staff is extremely professional and willing to help. Amazing team. If you have been afraid of the dentist, check them out and theyll change your mind about dentistry.
  • Rating: 5 Kennesaw Marietta Cosmetic Dentist - 5 Star Reviews 3
    My family and I love Dr. Vo. I would suggest this practice to anyone who wants a dentist and staff that truly care about your health and will go above and beyond the typical dentist. I followed Dr. Vo from a previous office, and although this office is farther away, it is worth it because of how caring the staff is.
  • Rating: 5 Kennesaw Marietta Cosmetic Dentist - 5 Star Reviews 4
    Switched to 32 dental after Dr. Breckley left Dr. Goetees practice. Great staff, and nice space. They use the latest technologies and have K cups in the waiting room!
  • Rating: 5 Kennesaw Marietta Cosmetic Dentist - 5 Star Reviews 5
    Dr. Vo is fantastic. She is patient, knowledgeable, and excellent at her job, and most importantly, she takes time to answer your questions and explain any concerns she has about your teeth, so you really know what\'s going on. It inspires me to take better care of my teeth. By far, she is the best dentist I have been been to, and I highly recommend her. No more of those dime-a-dozen dentists for me!
  • Rating: 5 Kennesaw Marietta Cosmetic Dentist - 5 Star Reviews 6
    Liked: Dr vo is awesome, Service, Staff
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