New Patient Registration Please enable JavaScript in your browser to complete this form.Patient's First Name *Patient's Last Name *Preferred Name *Date of BirthMarital StatusAddressCityUS StatesTexasAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingWashington DCARMED FORCES AFRICA CANADA EUROPE MIDDLE EASTARMED FORCES AMERICA (EXCEPT CANADA)ARMED FORCES PACIFICZipIf Patient Attends School Please Tell Us Where They Go?CityUS States TexasAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingWashington DCARMED FORCES AFRICA CANADA EUROPE MIDDLE EASTARMED FORCES AMERICA (EXCEPT CANADA)ARMED FORCES PACIFICWhom May We Thank For Referring You?Parent/Guardian Full NameDate of BirthAddressCityUS StatesTexasAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingWashington DCARMED FORCES AFRICA CANADA EUROPE MIDDLE EASTARMED FORCES AMERICA (EXCEPT CANADA)ARMED FORCES PACIFICZipRelationship To PatientCell/Home PhoneWork PhoneEmail *Social Security NumberOccupationDo you have insurance?Name of Policy Holder Policy Holder Date of BirthInsurance CompanyInsurance AddressCityUS StatesTexasAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingWashington DCARMED FORCES AFRICA CANADA EUROPE MIDDLE EASTARMED FORCES AMERICA (EXCEPT CANADA)ARMED FORCES PACIFICZipPhoneGroup NumberSubscriber IDPolicy Holder Social Security NumberRelationship To Policy HolderDo you have secondary insurance?Name of Policy HolderPolicy Holder Date of BirthInsurance CompanyInsurance AddressCityUS StatesTexasAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingWashington DCARMED FORCES AFRICA CANADA EUROPE MIDDLE EASTARMED FORCES AMERICA (EXCEPT CANADA)ARMED FORCES PACIFICZipInsurance Phone NumberGroup NumberPolicy Holder Social Security NumberSubscriber IDRelationship To Policy HolderName of Emergency ContactBest Contact NumberBest Contact AddressAre you currently under the care of a medical doctor? YesNoIf Yes, Physician Office NameIf Yes, Physician NamePhysician Phone NumberDate Of Last Physical ExamHave you been hospitalized or had surgeries within the last year? YesNoIf Yes, Please Explain;Are you taking any Prescriptions? Including Over The Counter and Prescriptions *YesNoPlease List All MedicationsFor Female Patients – Is The Patient Pregnant?YesNoFor Female Patients – Is The Patient Nursing An Infant?YesNoFor Female Patients – Is The Patient on Birth Control?YesNoDo you have pins, plates, screws, or artificial joints?YesNoHave you ever taken Fen-Phen or Redux? YesNoIf YES, did you have a cardio exam? YesNoDo you use tobacco? YesNoDo you use alcohol? YesNoDo you use recreational drugs? YesNoDo you wear contacts? YesNoHave you ever taken Fosamax, Boniva, Actonel, or any other medications containing Bisphosphonates? YesNoIf so, please list medicationsAre you allergic to any of the following?AspirinPenicillinCodeineAcrylicMetalLatexSulfa DrugsOther allergies:Have you ever bled excessively?YesNoIf So, Please ExplainHave you ever had complications with anesthesia? YesNoPlease Check If You Have The Following Current of Past Conditions:ADD/ADHDAIDSAlzheimer’s DiseaseAnemiaAngina PectorisArthritisAsthmaAutismBleeds/Bruises EasilyBlood TransfusionBone/Joint ProblemCancerChemotherapyChest painCleft Lip/PalateCold SoresCongenital Birth DefectCongenital Heart LesionsCortisone MedsDevelopment DelayDiabetesDown SyndromeDrug addictionEar Infection/RecurrentEating DisorderEmphysemaEpilepsyExcessive BleedingFainting/DizzinessFrequent CoughHearing/Visual ProblemsHeart AnomalyHeart Attack/FailureHepatitis A, B, or CHerpesHemophiliaHigh Blood PressureHigh CholesterolHIVHives/RashHypo/HyperthyroidHypoglycemiaImmune ComprimisedInfectious DiseaseGlaucomaKidney ProblemsLiver DiseaseLow Blood PressureLung DiseaseMitral Valve ProlapseNeurological DisorderNervousnessOsteoporosisPsychiatric TreatmentRespiratory ProblemsRheumatic FeverRheumatismScarlet FeverSeizuresShinglesSickle Cell AnemiaSinus TroubleStrokeStomach DiseaseThyroid DiseaseTuberculosisUlcersYellow JaundiceOther 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?YesNoHave you ever had an unpleasant experience at a dental office? YesNoHave you ever had trouble getting numb or a reaction to local anesthetic? YesNoAre your teeth sensitive to: HeatColdBiting PressureSweetsDoes your jaw pop or click? YesNoDo you clench or grind your teeth? YesNoAre your teeth becoming loose? YesNoDo you have frequent headaches and sore teeth? YesNoDo you snore or have you been told that you stop breathing in your sleep? OnceTwiceHave you ever had braces or other orthodontic treatment? YesNoDo you feel that your teeth are shifting/moving? YesNoDo you brush and floss daily? YesNoDo you have dry mouth? YesNoDo you gums ever bleed when you brush or floss? YesNoIs there ever an unpleasant taste or odor in your mouth? YesNoDo you smoke or use tobacco? YesNoIn 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 FieldI will inform the doctor/assistant/hygienist if there is any change in my medical or dental status.” prior to submitting formSingle 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.PhoneSubmit