New Dental Patient Registration Form

Patient Information

First name

Middle initial

Last name

Gender

Marital status

Full time student?

Birthdate mm/dd/yyyy

Email address

Mailing Address (number, street, unit #, city, state, zip code)

Preferred contact phone number

Okay to text/email communications?

Yes No

Employer/Occupation

Who referred you?

Parent or Guardian Information (Only If Patient is a dependent)

First name

Middle Initial

Last name

Birthdate mm/dd/yyyy

Email address

Address (number, street, unit #, city, state, zipcode)

Preferred contact phone number

Okay to text/email communications?

Yes No

I have dental insurance

Yes No

Primary Dental Insurance Information (If applicable)

Policy holder name

Policy holder birthdate mm/dd/yyyy

Dental insurance company

Subscriber number

Relationship of policy holder to patient

Secondary Dental Insurance Information (If applicable)

Policy holder name

Policy holder birthdate mm/dd/yyyy

Dental Insurance Company

Subscriber number

Relationship of policy holder to patient

Dental History

Date of last dental check-up mm/dd/yyyy

Date of last teeth cleaning mm/dd/yyyy

Date of last dental x-ray mm/dd/yyyy

Do you have or have you ever had any of the following?

Dentures

Orthodontic braces

Periodontal (gum) treatments

Dental Implants

TMJ treatment

Wisdom teeth extracted

Medical History

Do you have any of the following allergies?

Penicillin

Aspirin

Codeine

Tylenol

Sulfa

Latex

Local dental anesthetic

No known allergies

Other Allergies

Please List Medications

Your Smile

Are there any concerns you would like us to address?

By submitting this form, I affirm that it has been completed to the best of my knowledge and I authorize the disclosure of my dental records for the purpose of treatment, payment and healthcare operations as outlined in the HIPAA privacy practices document provided by our office.

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