Patient Registration

HIGH COUNTRY DENTAL

303-693-5600

20250 E Smoky Hill Rd #3, Centennial CO 80015

Patient Name

Preferred Name

Birthdate

Sex

Male Female

Mailing Address

City

State

Zip

Home Phone

Cell Phone

Work Phone

Email Address

SS#

Marital Status

Married Single Partnered Minor Widowed

Employer

Occupation

Full Name of Spouse/Parent

School

Who may we thank for the referral

Emergency contact (other than spouse) name and #

Primary Insurance

Insurance Company

Insured’s Name

Insured’s Employer

Insured’s ID/SSN#

Date of Birth

Group #

Secondary Insurance

Insurance Company

Insured’s Name

Insured’s Employer

Insured’s ID/SSN#

Date of Birth

Group #

Dental History

To serve you properly we will need the following information. All information will be strictly confidential.

Name of previous dentist

Phone

Location

Date of Last Exam

How often do you brush your teeth?

How often do you floss?

Does dental treatment make you nervous?

No Slighty Moderately Extremely

Do you need to be pre-medicated with an antibiotic prior to any dental treatment?

Have you ever had any trouble with previous dental treatment?

Yes No

If yes, what?

Have you ever been treated for Periodontal Disease (Gum Disease, Deep Cleaning, Gum Surgery)?

Yes No

If yes, when?

Indicate which of the following you have at the present. Choose Yes or No for each item.

Mouth

Bleeding Gums

Yes No

Unpleasant Taste/Bad Breath

Yes No

Frequent Sores (Lips/Mouth)

Yes No

Swelling/Lumps in Mouth

Yes No

Ortho Treatment (Braces)

Yes No

Clicking/Popping or Difficulty Opening/ Closing Jaw

Yes No

Dry Mouth

Yes No

Teeth

Teeth Sensitivity

Yes No

Difficulty Chewing

Yes No

Does Food Pack or Catch between Teeth?

Yes No

Clenching/Grinding

Yes No

Frequent Headaches

Yes No

Shifting of teeth

Yes No

Do you wear partials or dentures

Yes No

Do you like your smile?

Yes No

If you could change something about your smile what would it be?

Medical History

Physician’s Name

Physician’s Phone Number

Are you being treated for any Medical Condition at this present time?

Yes No

If yes, what condition(s) are you being treated for?

Have you ever been hospitalized or had a serious illness?

Yes No

If yes, reason

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

Latex materials

Penicillin or other antibiotics

Local anesthetics ("Novocain")

Codeine or other narcotics

Sulfa drugs

Barbiturates, sedatives, or sleeping pills

Aspirin

Metal Allergies/reactions

Other

If other, explain

Do you or have you taken Actonel, Boniva, Fosamax or any other medications containing bisphonates?

Yes No

Please list any medications you are taking including non-prescription or herbal/vitamins, and reason for taking

Have you ever had excessive bleeding following an extraction or problems clotting?

Yes No

Do you use tobacco in any form?

Yes No

If yes, how much and what type?

Do you have more than 2 alcoholic drinks per day?

Yes No

Do you use controlled substances?

Yes No

(Women Only)

Are you pregnant:

Yes No

If yes, expected delivery date

Nursing?

Yes No

Taking Birth Control Pill?

Yes No

Indicate which of the following you have at the present. Choose Yes or No for each item.

Anemia

Yes No

Artificial Heart Valve

Yes No

Arthritis, Rheumatism

Yes No

Artificial Joint, Pins, etc.

Yes No

If yes, when?

If yes,what?

Asthma

Yes No

Back Problems

Yes No

Bleeding Abnormally

Yes No

Blood Disease

Yes No

If yes. what?

Cancer/Radiation

Yes No

If yes, what kind of cancer?

Chemotherapy

Yes No

Circulatory Problems

Yes No

Diabetes

Yes No

Epilepsy/Convulsions

Yes No

Fainting

Yes No

Glaucoma

Yes No

Hay Fever

Yes No

Headaches

Yes No

Heart Attack

Yes No

Hepatitis

Yes No

Herpes

Yes No

High Blood Pressure

Yes No

HIV/AIDS

Yes No

Kidney Disease

Yes No

Liver Disease

Yes No

Low Blood Pressure

Yes No

Mitro Valve Prolapse

Yes No

Pacemaker/Heart Surgery

Yes No

Psychiatric Treatment

Yes No

Respiratory Disease

Yes No

Sinus Trouble

Yes No

Stomach Ulcers/Acid Reflux

Yes No

Stroke

Yes No

Swelling Feet/Ankles

Yes No

Thyroid Conditions

Yes No

Other

Yes No

If Other, please explain

Consent

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 understand the use of anesthetic agents embodies a certain risk.

I authorize the Doctor to release my 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 payers and/or health practitioners. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. I assign all benefits to the Doctor and request the insurance company pay the dentist directly.

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

Patient (Guardian) Signature

Date

Your information will be encrypted.