Patient Registration Form

Patient's Name

Date of Birth

Age

If student, name of school

If minor, name of legal guardian

Home Phone

Mobile Phone

Work Phone

Email address

Employer

Mailing address

City

State

Zip

Occupation

Whom may we thank for referring you to our office?

INSURANCE INFORMATION

Not covered by dental insurance Card/Insurance Documents

Your SS #

Member ID #

Dental Insurance Co.

Group No

Claims Address

Spouse's Name

Spouse's dental insurance company

Group number

Spouse's Birthday

SS# or Member ID#

Medical Health History

If Cancer, specify type

If Cancer, Year?

If Chemotherapy / Radiation, What year?

Are you allergic to, or have you reacted adversely to any of the following?

Penicillin or other antibiotics

Local anesthetics (numbing meds)

Codeine or other narcotics

Other

If Other, Please specify

Please list any medications you are taking.

DENTAL HISTORY

Chief dental concern

Former Dentist

Date of last dental visit

Date of last dental x-rays

Times-a-day you brush?

How often do you floss?

Are you interested in tooth whitening options?

Yes No

Are you concerned with the position of your teeth?

Yes No

I certify that I have provided the most accurate and up-to-date information.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature or patient or guardian

Date

Emergency Contact

Phone

Your information will be encrypted.