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New Patient Registration


  Last name

  Mid name

  First name
    
    
City
State
Zip
APT#
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()- -
City
State
Zip
APT#

Adult Patient Details

Single Married Partnered Divorced/Separated Widowed
()- -
    
()- - -

Employer Details
City
State
Zip
APT#

Relative or friend not living with you
()- - -
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Insurance information

Primary insurance
YesNo
City
State
Zip
APT#
()- -

Secondary insurance
YesNo
City
State
Zip
APT#
()- -

Dental history

Dental complaints/problem?
Yes No
Growth or sore spots in your mouth?
Yes No
Difficult extractions in the past?
Yes No
Prolonged bleeding after extraction?
Yes No
Wisdom teeth extracted?
Yes No
Periodontal surgery?
Yes No
Bleeding gums?
Yes No
Are you in pain now?
Yes No
Low back pain?
Yes No
Pain in or near your ears/jaw?
Yes No
Loose or sensitive teeth?
Yes No
Which side?
Chronic headaches, neck or shoulder pain?
Yes No
A clicking jaw? Sometimes Always
Yes No
Bleaching, either at home or by a dentist? Home Dentist
Yes No
Unhealed injuries or inflammations in or around your mouth?
Yes No
“Trench mouth” or other gum conditions?
Yes No
Reaction to anesthetic (i.e. Novacaine)?
Yes No
Mouth sensitivity to pressure or irritants(i.e. cold, sweets, etc.)?
Yes No
Removable/fixed dentures or other appliances?
Yes No
Instruction on the correct method of brushing your teeth?
Yes No
Instruction on the care of your gums?
Yes No
Do you chew on one side of your mouth? Left Right
Yes No
Do you clench, grind or brux (gnash) your teeth?
Yes No
Does any part of your mouth hurt when clenched?
Yes No
Do your teeth and/or jaws ever feel “tired” when you wake up?
Yes No
Do you have now, or have you ever had pain in your jaw or in the sides of your face about your ears?
Yes No
Have you ever had partial or full-mouth orthodontic treatment?
Yes No
Has antibiotic pre-medication prior to dental work ever been advised by your physician?
Yes No
DO YOU SNORE WHEN SLEEPING?
Yes No
Have you ever had problems with prior dental treatment?
Yes No
Explain

Medical History

YesNo
()- -
Good Fair Poor
YesNo
YesNo
Why :
YesNo
Explain :
Chest pain (angina)?
Yes No
Sinus problems?
Yes No
Blurred vision?
Yes No
Swollen ankles?
Yes No
Difficulty swallowing?
Yes No
Seizures?
Yes No
Shortness of breath?
Yes No
Frequent vomiting or nausea?
Yes No
Jaundice?
Yes No
Recent weight loss, fever or night sweats?
Yes No
Dizziness?
Yes No
Excessive thirst?
Yes No
Persistent cough or coughing up blood?
Yes No
Ringing in ears?
Yes No
Dry mouth?
Yes No
Bleeding problems or brusing easily?
Yes No
Headaches?
Yes No
Frequent urination?
Yes No
Joint pain or stiffness?
Yes No
Fainting spells?
Yes No
Mood swings?
Yes No
YesNo
YesNo
YesNo
Heart disease
AIDS or ARC
Prosthetic heart valve
Heart attack or heart defects
HIV positive
Artificial joint
Heart murmurs
Tumor or cancer
Blood transfusions
Rheumatic fever
Skin diseases
Psychiatric care
Pacemaker
Anemia
Emotional disorder
Stroke or hardening of arteries
Venereal disease
Kidney/bladder disease
High blood pressure
Herpes
Arthritis
Chemotherapy and/or Radiation
Contact lenses
Family history of heart disease
Implants
Stomach problems or ulcers
Eye disease
Family history of diabetes or tumors
Hospitalization
Thyroid or adrenal disease
Hepatitis or other liver disease
Surgeries
Diabetes
TB, asthma, emphysema or lung disease
Treatment for osteoporosis?
Bisphosphonate drugs (Fosamax®, Aredia®, Zometa®, Actonel®, Boniva®)
When?
Recreational drugs
Tobacco (in any form)
Alcohol
Bisphosphonates (IV, etc.)
Drug dependent
Dietary/Herbal supplements
Abused drugs
Latex allergies
Metal allergies
Drugs such as fen-phen for weight loss
Drugs. Medicines (incl. aspirin)
Please List:

RESPONSIBILITY AND CONSENT STATEMENT

* To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication. I certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form. The undersigned hereby authorizes Doctor to initiate a collection of records for my comprehensive exam, consisting of radiographs, study models, photographs, or any other diagnostic aids deemed appropriate by Doctor to make a thorough diagnosis of the patient’s dental needs. I also authorize Doctor to perform any and all forms of treatment, medication and therapy, that may be indicated in connection with the patient named on this form and further authorize and consent that Doctor choose and employ such assistance as he deems fit. I also understand the use of anesthetic agents embodies a certain risk. I understand the responsibility for payment for Dental Services provided in this office for myself or my dependent’s is mine, due and payable at the time services are rendered regardless of insurance coverage. I agree that Doctor’s office will assist me in submitting all insurance claims as a courtesy only and that one claim per patient per visit will be submitted to my insurance carrier at no cost. I further acknowledge that any insurance coverage that I may have is an agreement between my insurance company, myself and/or my employer. I understand that a service charge of 1% per month (12% APR) is incurred on any unpaid balance after 30 days from the date the service was provided. If my account is referred for collection, I will be responsible for any attorney’s fees and court costs necessary to collect the unpaid balance.

*Signature :
Date :
(Your digital signature (full name) is as legally binding as a physical signature.)