Patient Registration Form

Patient's Name

Date

DENTAL HISTORY

Patient Name

Patient Account No

Medical Alert

Welcome! So that we may provide you with the best possible care please complete both sections of this medical/dental history form. All information is completely confidential.

What is the reason for your visit today?

Date of Last Dental Visit?

Last Dental Cleaning

Last Full Mouth X-Rays

What was done at your last dental visit?

Previous Dentist's Name

Address

Telephone No.

How often do you have dental examinations?

How often do you brush your teeth?

How often do you floss?

What other dental aids do you use? (interplak, toothpick, etc)

If yes, please describe

Are any of your teeth sensitive to:

If yes where?

HAVE YOU EVER HAD

If so, please describe, including cause

HAVE YOU EXPERIENCED

If so, what is your biggest concern?

if yes, please describe

If yes, please describe

MEDICAL HISTORY

Although dental personnel primarily treat the area in and around your mouth, your mouth is part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

If yes, for what?

Physician's Name

Phone No.

If yes, Why?

If yes, How often?

If yes, please list prescribed/over the counter meds:

Are you allergic to any of the following?

Aspirin

Penicillin

Codeine

Acrylic

Metal

Latex

Sulfa Drugs

Local Anesthetics

Other

If yes, Please list

If yes, How may months?

To the best of my acknowledgment, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes.

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.

Parent/Guardian Signature

Date

Your information will be encrypted.

Patient Registration Form

DENTAL HISTORY

Are any of your teeth sensitive to:

MEDICAL HISTORY

Michael J Morris, DDS