canstockphoto0585131-1-1024x673 smallIf you have not visited our dental office before, please fill out the Patient Registration form below as completely as possible, and then click “Send” to submit it to our office.

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First Name* Last Name * MI

Your Email *

Patient is: *
Policy HolderResponsible Party



Responsible Party (If other than patient):

First Name* Last Name * MI

Address *

City * State * Zip *
Home * Work Cellular
Birth Date * SSN DL# *

Responsible Party is also Policy Holder for PatientPrimary Insurance Policy HolderSecondary Insurance Policy Holder


Patient Information

Address *

City * State * Zip *
Home * Work Cellular
Birth Date * SSN DL# *

Sex*
MaleFemale

Marital Status*
MarriedSingleDivorcedSeparatedWidowed

Email *
I would like to receive correspondence via e-mail


Employment Status * Full TimePart TimeRetired
Student Status: * Full TimePart Time
Referred By:
Previous Dentist:
Employer ID: Carrier ID:


Primary Insurance Information

Name of Insured: *
Relationship to Insured: * SelfSpouseChildOther
Insured SSN Birth Date: *
Employer: * Ins. Company: *
Address: * Address: *
City, State, Zip: * City, State, Zip: *


Secondary Insurance Information

Name of Insured:
Relationship to Insured: SelfSpouseChildOther
Insured SSN: Birth Date:
Employer: Ins. Company:
Address: Address:
City, State, Zip: City, State, Zip:


Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is part of your entire body. Health problems that you may have, or medications that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.


Are you under a physician's care now? * YesNo
If yes, please explain:
Have you ever been hospitalized or had a major operation? * YesNo
If yes, please explain:
Have you ever had a serious head or neck injury? * YesNo
If yes, please explain:
Are you taking any medications, pills, or drugs? * YesNo
If yes, please explain:
Do you take, or have you taken, Phen-Fen or Redux? * YesNo
If yes, please explain:
Are you on a special diet? * YesNo
If yes, please explain:
Do you use tobacco? * YesNo
If yes, please explain:
Do you use controlled substances? * YesNo
If yes, please explain:
Women: Are you
Pregnant/Trying to get pregnantNursingTaking oral contraceptivesNot Trying


Are you allergic to any of the following?
AspirinPenicillinCodeineAcrylicMetalLatexLocal AnestheticsOther
If yes, please explain:


Do you have, or have you had, any of the following? *

AIDS/HIV PositiveChest PainsFrequent HeadachesIrregular Heartbeat Scarlet FeverAlzheimer's DiseaseCold Sores/Fever BlistersGenital Herpes
Kidney ProblemsShinglesAnaphylaxisChest Pains Congenital Heart DisorderGlaucomaLeukemiaSickle Cell Disease
AnemiaCortisone MedicineHeart Attack/FailureLow Blood Pressure Spina BifidaArthritis/GoutDiabetesHeart Murmur
Lung DiseaseStomach/Intestinal DiseaseArtificial Heart ValveDrug Addiction Heart Pace MakerMitral Valve ProlapseStrokeArtificial Joint
Easily WindedHeart Trouble/DiseasePain in Jaw JointsSwelling of Limbs AsthmaEmphysemaHemophiliaParathyroid Disease
Thyroid DiseaseBlood DiseaseEpilepsy or SeizureHepatitis A Psychiatric CareTonsillitisBlood TransfusionExcessive Bleeding
Hepatitis B or CRadiation TreatmentTuberculosisBreathing Problem Excessive ThirstHerpesRecent Weight LossTumors or Growths
Bruise EasilyFainting Spells/DizzinessHigh Blood PressureRenal Dialysis UlcersCancerFrequent CoughHives or Rash
Rheumatic FeverVenereal Disease ChemotherapyFrequent Diarrhea
RheumatismYellow Jaundice Hypoglycemia

Have you ever had any serious illness not listed above?*
YesNo

If yes, please explain:

Dental History

Date of last dental visit *

Name of previous dentist *

Reason for today's visit *

Do you have a problem with any of the following? *

Bad breathLoose teethJaw popping Sensitivity to sweetsPoor Fitting DenturesSensitivity to hot/cold Sores in your mouthDry mouthGrinding teeth Bleeding gumsUnattractive smileStained teeth


Comments


To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status. (must agree for form to submit)