Patient Registration Forms

Welcomes you

To help us meet all your healthcare needs, please fill out this form completely in ink. If you have any questions or need assistance, please ask us and we will be happy to help.

Patient Information

Name

Patient Number

Date

SS#/SSN

Birthdate

Home Phone

Cell Phone

Address

City

State / Province

Zip / P.C.

Check Appropriate Box:

Minor

Single

Married

Separated

Divorced

Widowed

If Student, Name of School/College

City

State / Province

Patient or Parent/Guardian’s Employer

Work Phone

Business Address

City

State / Province

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 (For Parent/Guardian)

Name of Person Responsible for this Account

Relationship to Patient

Address

City

State

Zip Code

Home Phone

Cell Phone

Driver’s License #

Birthdate

Financial Institution

Employer

Work Phone

SS#/SIN

Is this Person Currently a Patient in our Office?

Yes No

For your convenience, we offer the following methods of payment. Please check the option you prefer. Payment in full at each appointment.

Cash Personal Check Visa (Credit Card) MasterCard (Credit Card) I wish to discuss the office’s payment policy.

Insurance Information

Name of insured

Relationship to Patient

Birthdate

SS#/SIN

Date Employed

Name of Employer

Union or Local #

Work Phone

Employer Address

City

State/Prov.

Zip/P.C.

Insurance Company

Group #

Policy/ID#

Ins. Co. Address

City

State/Prov.

Zip/P.C.

How Much is Your Deductible?

How Much Have You Used?

Max. Annual Benefit

Do You Have Any Additional Insurance?

Yes No

If Yes, Complete the Following

Add Additional Insurance

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 Sulfa Drugs non-prescription medicine?

Yes No

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

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

Yes No

5. Have you ever taken Fosamax, Boniva, Actonel or any Cancer medications containing bisphosphonates?

Yes No

6. Have you taken Viagra, Revatio, Cialis or Levitra in the last 24 hours?

Yes No

7. Do you use tobacco/vape?

Yes No

8. Do you use controlled substances?

Yes No

If Other, Please specify

10. Are you wearing contact lenses?

Yes No

If Other, Please specify

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

Yes No

Women only:

Are you pregnant or think you may be pregnant?

Yes No

Are you nursing?

Yes No

Are you taking oral contraceptives?

Yes No

Patient Dental History

Name of Previous Dentist

Previous Dentist's Location

Date of Last Exam

1. Do your gums bleed while brushing or flossing?

Yes No

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

Yes No

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

Yes No

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

Clicking

Pain (joint, ear, side of face)

Difficulty in opening or closing

Difficulty in chewing

5. Do you have frequent headaches?

Yes No

6. Do you clench or grind your teeth?

Yes No

7. Do you bite your lips or cheeks frequently?

Yes No

8. Have you ever had any difficult extractions In the past?

Yes No

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

Yes No

10. Have you had any orthodontic treatment?

Yes No

11. Do you wear dentures or partials?

Yes No

If yes, date of placement

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

Yes No

13. Do you like your smile?

Yes No

14. Do you experience dry mouth?

Yes No

15. Have you had known exposure to COVID-19?

WAS YOUR LAST CLEANING WITHIN THE LAST 3 YEARS?

WHEN WAS YOUR LAST CLEANING?

HAVE YOU EVER HAD A DEEP CLEANING?

HAVE YOU HAD RECENT MAINTENANCE?

ARE YOU UNDER 30 YEARS OF AGE?

DATE OF MAINTENANCE

I HAVE BEEN TOLD I HAVE SOME BONE LOSS IN THE PAST AND BELIEVE I AM PREVENTING FURTHER LOSS BY MY CURRENT HYGIENE PRACTICES? (NO TO 2 OR MORE ABOVE MAY INDICATE THE NEED FOR A DEEP CLEANING)

HAVE YOU TRAVELED OUTSIDE OF THE U.S.A?

IF SO, WHAT COUNTRY?

ARE YOU IN PAIN?

HOW LONG HAVE YOU BEEN IN PAIN?

ARE YOUR TEETH SENSITIVE TO HOT/COLD FOODS OR LIQUIDS?

IS THE TOOTH CHIPPED OR CRACKED?

DOES THE PAIN KEEP YOU UP AT NIGHT?

IS PAIN DULL, SHARP OR THROBBING?

DOES PAIN LINGER?

WOULD YOU LIKE TO SAVE THE TOOTH IF POSSIBLE (YES TO 5 OR MORE CONSIDER ROOT CANAL OR EXTRACTION)

IF YOU LOSE A FRONT TOOTH WOULD YOU LIKE A TEMPORARY REPLACEMENT?

HOW MANY MISSING TEETH DO YOU HAVE?

PLEASE INDICATE EXTRACTION DATES

HAVE THEY BEEN REPLACED?

WHY NOT? (If answered no on previous question)

WOULD YOU LIKE MISSING TEETH REPLACED?

WOULD YOU PREFER A MOVABLE OR PERMANENT REPLACEMENT?

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 and his/her associates to release and/or obtain 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 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 responsible for payment of all services rendered on my behalf or my dependents and authorize a credit check for the purpose of obtaining financing for my portion of the treatment planned. This may include an application to our financial partners such as; Care Credit, Wells Fargo, Lending Club, Alphaeon, and One Main, among others.

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)

Date:

Office use only:

Processor’s signature:

Date

Your information will be encrypted.