Patient Registration Form

Thank you for choosing our office. In order to serve you properly, please answer all questions on BOTH sides, so that we may diagnose your oral health as accurately as possible. All information will be kept strictly confidential.

PATIENT’S NAME:

PREFERRED NAME:

Social Security No:

Birthdate:

Mailing Address:

Email:

City:

State:

Zip Code:

Home Phone No.:

Cell Phone No:

Patient Occupation:

Employer:

Work Phone:

Name of Spouse/Partner:

Birthdate:

SSN:

Spouse Occupation:

Employer:

Work Phone:

IN CASE OF EMERGENCY, WHOM MAY WE CONTACT? (Other than someone living with you)

Name:

Home Ph. No.:

Work Ph. No.:

Relationship to patient:

WHOM MAY WE THANK FOR REFERRING YOU TO US?

Payment Is Expected At Time Of Each Visit

Please Check Method of Payment:

Cash Check Bankcard Other

If "Other" is selected, please specify:

Person responsible for payment:

Responsible persons address:

Phone#:

Primary Dental Insurance

Subscriber:

Subscriber ID#:

Subscriber D.O.B.

Subscriber Address

Subscriber Phone#:

Relationship to Patient:

Employer:

Insurance Co.:

Group#:

Insurance Address:

Insurance Phone#:

Secondary Dental Insurance

Subscriber:

Subscriber ID#:

Subscriber D.O.B.:

Subscriber Address:

Subscriber Phone #:

Relationship to Patient:

Employer:

Insurance Co:

Group#:

Insurance Address:

Insurance Phone #:

CONSENT TO TREATMENT

I grant authority to the dentist(s) in charge of the care of the patient whose name appears on this Health History form, to administer upon explanation such anesthetics, analgesics, sedatives, nitrous oxide sedation; and to perform such operations as may be deemed necessary or advisable in the diagnosis and treatment of this patient. I grant my permission to you, or your assigns, to telephone me at home or at my work to discuss matters related to this form.

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.

Patient's Name:

Date:

MEDICAL HISTORY

Are you currently under the care of a physician?

Yes No

If yes, please give the City/State and Phone#:

Name of current physician or medical specialist:

List Medications/Herbal Supplements currently taking, dosage and condition:

If Diabetes is selected, please specify:

Type I Type II

If Other is selected, please specify:

Are you allergic to or have you reacted adversely to any of the following? (check all that apply)

Aspirin

Codeine

Latex

Local Anesthetic

Penicillin

Other Antibiotics

List any other allergies here:

Do you Smoke?

Yes No

Use Smokeless Tobacco?

Yes No

Use E-Cigarettes?

Yes No

Are you currently being treated for cancer or have you been treated in the past for cancer?

Yes No

Type of treatment:

Are you or could you be pregnant?

Yes No

Are you nursing?

Yes No

Are you taking Birth Control pills?

Yes No

Have you undergone Osteoporosis Therapy?(e.g.: Fosamax, Actonel, Boniva)

Yes No

Are you now or have you ever been addicted to a chemical substance? (e.g.: Alcohol, Prescription Drugs, Heroin, Meth, Cocaine, Other)

Yes No

How do you rate your sleep 1-10?

Do you snore?

Yes No

or Have you been told that you snore?

Yes No

Do you have any disease, condition or concern not listed that you believe that we should know about? (please list)

DENTAL HISTORY

Purpose of Appointment:

How long since your last dental treatment:

When was your last dental cleaning?

Name of previous Dentist:

City/State:

Phone#:

Have you had any unpleasant dental experiences or is there anything about dentistry that you strongly dislike:

Yes No

Have you ever had any trouble or complications with previous dental treatment?

Yes No

If yes, explain:

Have you ever been diagnosed with gum disease?

Yes No

Gum treatment or surgery?

Yes No

Do you clench or grind your teeth?

Yes No

Do you wear a nightguard?

Yes No

Have your teeth changed in the last 5 years?

Yes No

If yes, please select (check all that apply):

shorter

thinner

worn

cosmetic

Do you experience frequent (check all that apply)

headaches?

neck aches?

shoulder aches?

Muscle pain/soreness of your face or around your ear?

Yes No

Do you have jaw or jaw joint problems?

Yes No

If yes, please select (check all that apply):

pain

sounds

limited opening

locking

popping

Do you have more than one bite or do you need to clench (squeeze) to make your teeth fit together?

Yes No

Do you have difficulty with chewing gum?

Yes No

Chewy or hard foods?

Yes No

How do you rate your smile 1-10?

Where do you want it to be 1-10?

What would it take to get your smile there?

I understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.

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.

Patient's Name:

Date:

Update Record

Date:

Initial:

Add new row

Your information will be encrypted.