New Patient Registration Form

Welcome

Thank you for selecting our dental healthcare team! We will strive to provide you with the best possible dental care. To help us meet all your dental healthcare needs, please fill out this form completely, If you have any questions or need assistance, please ask us - we will be happy to help.

Patient lnformation (Confidential)

Name

Birthdate

SS#/SIN

Home Phone

Date

Address

City

State/Prov.

Zip P.C.

CelI Phone

Check Appropriate Box

Minor Single Married Divorced Widowed Separated

If Student, Name of School/College

City

State/Prov.

Student Status

Full Time Part Time

Patient's or Parent/Guardian's Employer

Work Phone

Business Address

City

State/Prov.

Zip P.C.

Spouse or Parent/Guardian's Name

Employer

Work Phone

Whom May We Thank for Referring You?

Person to Contact in Case of Emergency

Phone

Responsible Party

Name of Person Responsible for this Account

Relationship to Patient

Address

Home Phone

CeII Phone

Driver's License #

Birthdate

Employer

Work Phone

SS#/SIN

Is this Person Currently a Patient in our office?

Yes No

Insurance Information

Name of Insured

Relationship to Patient

Birthdate

SS#/SIN

Date Employed

Name of Employer

Union or Local #

Work Phone

Address of Employer

City

State/Prov.

Zip P.C.

Insurance Company

Group #

PoIicy/ID #

Do you have any additional Insurance

Yes No

Add new row

Patient Medical History

Physician

Office Phone

Date of Last Exam

1. Are you under medical treatment NOW?

Yes No

2. Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years?

Yes No

If yes, please explain

3. Are you taking any medication(s) including non-prescription medicine?

Yes No

If yes, what medication(s) are you taking?

4. Have you ever taken Phen-Fen/Redux?

Yes No

5. Do you use tobacco?

Yes No

6. Do you use controlled substances?

Yes No

7. Are you wearing contact lenses?

Yes No

8. Do you have or have you had any of the following?

High Blood Pressure

Yes No

Heart Disease

Yes No

Chest Pains

Yes No

Heart Attack

Yes No

Cardiac Pacemaker

Yes No

Easily Winded

Yes No

Rheumatic Fever

Yes No

Heart Murmur

Yes No

Stroke

Yes No

Swollen Ankles

Yes No

Angina

Yes No

Hay Fever / Allergies

Yes No

Fainting / Seizures

Yes No

Frequently Tired

Yes No

Tuberculosis

Yes No

Asthma

Yes No

Anemia

Yes No

Radiation Therapy

Yes No

Low Blood Pressure

Yes No

Emphysema

Yes No

Glaucoma

Yes No

Epilepsy / Convulsions

Yes No

Cancer

Yes No

Recent Weight Loss

Yes No

Leukemia

Yes No

Arthritis

Yes No

Liver Disease

Yes No

Diabetes

Yes No

Joint Replacement or Implant

Yes No

Heart Trouble

Yes No

Kidney Diseases

Yes No

Hepatitis / Jaundice

Yes No

Respiratory Problems

Yes No

AIDS or HIV Infection

Yes No

Sexually Transmitted Disease

Yes No

Mitral Valve Prolapse

Yes No

Thyroid Problem

Yes No

Stomach Troubles / Ulcers

Yes No

Other

Yes No

If Other, please specify

9. Are you allergic to, or have you had any reactions to the following?

Local Anesthetics (e.g. Novocain)

Yes No

Penicillin or any other Antibiotics

Yes No

Sulfa Drugs

Yes No

Barbiturates

Yes No

Sedatives

Yes No

Iodine

Yes No

Aspirin

Yes No

Any Metals (e.g. nickel, mercury, etc.)

Yes No

Latex Rubber

Yes No

Other

Yes No

If Other, please specify

10. Do you have a persistent cough or throat clearing not associated with a known illness (lasting more than 3 wks.)

Yes No

11. Women Only

a) Are you pregnant or think you may be pregnant?

Yes No

b) Are you nursing?

Yes No

c) Are you taking oral contraceptives?

Yes No

Patient Dental History

Name of Previous Dentist

Previous Dentist's Phone Number

Date of Last Exam

1. Do your gums bleed while brushing or flossing?

Yes No

2. Are your teeth sensitive to hot or cold liquids/foods?

Yes No

3. Are your teeth sensitive to sweet or sour liquids/foods?

Yes No

4. Do you feel pain to any of your teeth?

Yes No

5. Do you have any sores or lumps in or near your mouth?

Yes No

6. Have you had any head, neck or jaw injuries?

Yes No

7. Have you ever experienced any of the following problems in your jaw?

Clicking

Yes No

Pain (joint, ear, side of face)

Yes No

Difficulty in opening or closing?

Yes No

Difficulty in chewing?

Yes No

8. Do you have frequent headaches?

Yes No

9. Do you clench or grind your teeth?

Yes No

10. Do you bite your lips or cheeks frequently?

Yes No

11. Have you ever had any difficult extractions in the past?

Yes No

12. Have you ever had any prolonged bleeding following extractions?

Yes No

13. Have you had any orthodontic treatment?

Yes No

14. Do you wear dentures or partials?

Yes No

If yes, date of placement

15. Have you ever received oral hygiene instructions regarding the care of your teeth and gums?

Yes No

16. Do you like your smile?

Yes No

Authorization and Release

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such Dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be one responsible for payment of all services rendered on my behalf or my dependents.

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 of patient (or parent/guardian if minor)

Your information will be encrypted.

New Patient Registration Form

Welcome

Patient lnformation (Confidential)

Responsible Party

Insurance Information

Patient Medical History

9. ***Are you allergic to, or have you had any reactions to the following?***

Patient Dental History

Authorization and Release

9. Are you allergic to, or have you had any reactions to the following?