New Patient Registration

Patient's First Name *

Patient's Last Name *

Preferred Name *

Date of Birth

Marital Status

Address

City

US States

Zip

If Patient Attends School Please Tell Us Where They Go?

City

US States

Whom May We Thank For Referring You?

Parent/Guardian Full Name

Date of Birth

Address

City

US States

Zip

Relationship To Patient

Cell/Home Phone

Work Phone

Email *

Social Security Number

Occupation

Do you have insurance?

Name of Policy Holder

Policy Holder Date of Birth

Insurance Company

Insurance Address

City

US States

Zip

Phone

Group Number

Subscriber ID

Policy Holder Social Security Number

Relationship To Policy Holder

Do you have secondary insurance?

Name of Policy Holder

Policy Holder Date of Birth

Insurance Company

Insurance Address

City

US States

Zip

Insurance Phone Number

Group Number

Policy Holder Social Security Number

Subscriber ID

Relationship To Policy Holder

Name of Emergency Contact

Best Contact Number

Best Contact Address

Are you currently under the care of a medical doctor?

Yes
No

If Yes, Physician Office Name

If Yes, Physician Name

Physician Phone Number

Date Of Last Physical Exam

Have you been hospitalized or had surgeries within the last year?

Yes
No

If Yes, Please Explain;

Are you taking any Prescriptions? Including Over The Counter and Prescriptions *

Yes
No

Please List All Medications

For Female Patients – Is The Patient Pregnant?

Yes
No

For Female Patients – Is The Patient Nursing An Infant?

Yes
No

For Female Patients – Is The Patient on Birth Control?

Yes
No

Do you have pins, plates, screws, or artificial joints?

Yes
No

Have you ever taken Fen-Phen or Redux?

Yes
No

If YES, did you have a cardio exam?

Yes
No

Do you use tobacco?

Yes
No

Do you use alcohol?

Yes
No

Do you use recreational drugs?

Yes
No

Do you wear contacts?

Yes
No

Have you ever taken Fosamax, Boniva, Actonel, or any other medications containing Bisphosphonates?

Yes
No

If so, please list medications

Are you allergic to any of the following?

Other allergies:

Have you ever bled excessively?

Yes
No

If So, Please Explain

Have you ever had complications with anesthesia?

Yes
No

Please Check If You Have The Following Current of Past Conditions:

Other Medical Conditions:

What is the reason for today's visit?

How long has it been since you last dental visit?

Were dental x-rays taken?

Yes
No

Have you ever had an unpleasant experience at a dental office?

Yes
No

Have you ever had trouble getting numb or a reaction to local anesthetic?

Yes
No

Are your teeth sensitive to:

Heat
Cold
Biting Pressure
Sweets

Does your jaw pop or click?

Yes
No

Do you clench or grind your teeth?

Yes
No

Are your teeth becoming loose?

Yes
No

Do you have frequent headaches and sore teeth?

Yes
No

Do you snore or have you been told that you stop breathing in your sleep?

Once
Twice

Have you ever had braces or other orthodontic treatment?

Yes
No

Do you feel that your teeth are shifting/moving?

Yes
No

Do you brush and floss daily?

Yes
No

Do you have dry mouth?

Yes
No

Do you gums ever bleed when you brush or floss?

Yes
No

Is there ever an unpleasant taste or odor in your mouth?

Yes
No

Do you smoke or use tobacco?

Yes
No

In general, how do you feel about your overall dental health?

Are you dissatisfied with the way your teeth look? If so, please explain (i.e. shape, color, and alignment):

Is there anything that has not been covered on this form that you would like to share with us regarding your overall dental history?

Single Checkbox Field

I will inform the doctor/assistant/hygienist if there is any change in my medical or dental status.” prior to submitting form

Single Checkbox Field (copy)

I certify that I have read and understand the above information. To the best of my knowledge, the above questions have been answered accurately. I understand that providing false or incorrect information can be dangerous to the patients health.

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(469) 340-4002

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