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# *


Marital Status*

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 SSNBirth 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:
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 HeartbeatScarlet FeverAlzheimer's DiseaseCold Sores/Fever BlistersGenital Herpes
Kidney ProblemsShinglesAnaphylaxisChest PainsCongenital Heart DisorderGlaucomaLeukemiaSickle Cell Disease
AnemiaCortisone MedicineHeart Attack/FailureLow Blood PressureSpina BifidaArthritis/GoutDiabetesHeart Murmur
Lung DiseaseStomach/Intestinal DiseaseArtificial Heart ValveDrug AddictionHeart Pace MakerMitral Valve ProlapseStrokeArtificial Joint
Easily WindedHeart Trouble/DiseasePain in Jaw JointsSwelling of LimbsAsthmaEmphysemaHemophiliaParathyroid Disease
Thyroid DiseaseBlood DiseaseEpilepsy or SeizureHepatitis APsychiatric CareTonsillitisBlood TransfusionExcessive Bleeding
Hepatitis B or CRadiation TreatmentTuberculosisBreathing ProblemExcessive ThirstHerpesRecent Weight LossTumors or Growths
Bruise EasilyFainting Spells/DizzinessHigh Blood PressureRenal DialysisUlcersCancerFrequent CoughHives or Rash
Rheumatic FeverVenereal DiseaseChemotherapyFrequent Diarrhea
RheumatismYellow JaundiceHypoglycemia

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

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 poppingSensitivity to sweetsPoor Fitting DenturesSensitivity to hot/coldSores in your mouthDry mouthGrinding teethBleeding gumsUnattractive smileStained teeth


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)