Click on Calendar, type the year 'YYYY' and pick the month & date.
New Patient Registration


  Last name

  MidI

  First name
    
    

Driver’s license#:
Single Married Separated Widowed
City
State
 Zip
APT#
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Cell phone #:
()- -
()- - -
Yes No

If Patient is Minor -

  Last name

  Mid name

  First name

  Last name

  Mid name

  First name

Person Responsible For Account -

Spouse's Details or If Minor Parent's Details -
Work phone #:
()- - -

Emergency Contact Information
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City
State
 Zip
APT#

Any other Family in the Household (Kids, Husband, Wife, etc.)-
Name Age Currently Seeing a Dentist?
Yes No
Yes No
Yes No

Dental Insurance Information

Primary Carrier
City
State
 Zip
APT#
()- -

If You Have A Dual Insurance Coverage, Complete This For The Second Coverage.
(This Office Bills Primary Ins Only)
City
State
 Zip
APT#
()- -

Dental history

Sensitivity (Hot, Cold, Sweet)   Where? UR LR UL LL
Headaches, Ear aches, Neck or jaw joint pain.
Mouth ulcers or cold sores
Teeth or filling breaking
Grinding or clenching teeth
Bleeding, swollen or irritated gums
Loose, tipped or shifting teeth
Bad breath

Do you smoke or use chewing tobacco? Yes No
How much? For how long?

Make my teeth whiter
Make my teeth straighter
Close spaces
Have a smile makeover
Repair chipped teeth
Replace missing teeth
Replace old crowns that don't match
Replace metal fillings with tooth colored restorations

Crowns
Missing Teeth
Braces
Gum Treatments

How important is your dental health to you?
1 2 3 4 5 6 7 8 9 10
Where would you rate your current dental health?
1 2 3 4 5 6 7 8 9 10
Where would you like your dental health to be?
1 2 3 4 5 6 7 8 9 10



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City
State
Zip

Medical history

Have you had any of the following-
Allergies (Seasonal) Yes No Anemia Yes No
Artificial Heart Valve Yes No Artificial Joints Yes No
Asthma Yes No
If you have Asthma, have you ever had to go to a hospital or emergency room for treatment? Yes No
Blood Disease Yes No Bruise Easily Yes No
Cancer Yes No Chemotherapy Yes No
Diabetes Yes No Dizziness/Fainting Yes No
Drug Addiction Yes No Emphysema Yes No
Excessive Bleeding Yes No Glaucoma Yes No
Heart Conditions Yes No Heart Murmur Yes No
Hepatitis A Yes No Hepatitis B Yes No
Hepatitis C Yes No Chronic Pain Yes No
High Blood Pressure Yes No HIV/AIDS Yes No
Jaundice Yes No Kidney Disease Yes No
Liver Disease Yes No Mitral Valve Prolapse Yes No
Nervousness/Depression Yes No Pacemaker Yes No
Phen Fen (1 month +) Yes No Radiation (head/neck) Yes No
Respiratory Problems Yes No Rheumatic Fever Yes No
Rheumatism Yes No Scarlet Fever Yes No
Seizures Yes No Stomach Problems Yes No
Stroke Yes No Thyroid Disease Yes No
Tuberculosis Yes No Ulcers Yes No
Snoring Yes No Sleep Apnea Yes No
Fatigue Yes No Migraines Yes No
Other Yes No

Aspirin
Erythromycin
Latex
Local Anesthetic
Nitrous Oxide
Penicillin
Codeine
Other

Have you taken any medication for Osteoporosis or any bone density condition? Yes No
Birth Control Pills
Breast-Feeding
Pregnant    1-3 months 3-6 months 6-9 months

Are you under a physician's care Yes No
For What?
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*Signature :
Date :
(Your digital signature (full name) is as legally binding as a physical signature.)