Course Registration Form

Desert Breeze Dentistry

Patient Information
Date

Month Day Year
Date
Gender
Patient's Name

Last Name First Name Middle Name
Preferred Name
Family Status
Birth Date

Month Day Year
Social Security#
Email
example@example.com
Are you able to receive text message

Yes No
Phone Number
Home

Area Code Phone Number
Cell

Area Code Phone Number
Work

Area Code Phone Number
Work Ext

Address

Street Address
Street Address Line 2
City	State
Zip Code	Country

Occupation
Employer
Whom may we thank for referring you to our office?
If not a patient then please list source of referral:
Contact in case of an emergency?
Name of Contact
Phone Number

Area Code Phone Number
Responsible Party

(If different from above)
Patient's Name

Last Name First Name Middle Name
Phone Number

Area Code Phone Number

Address

Street Address
Street Address Line 2
City	State
Zip Code	Country

Birth Date

Month Day Year
Social Security#
Relationship to Patient? (spouse, guardian, etc.)
Primary Dental Insurance Information
Insured’s Name:

Last Name First Name Middle Name
Insured’s Soc. Sec. #
Birth Date

Month Day Year
ID #
Insurance Company:
Group #
Insurance Co. Address:
Insurance Co. Phone #

Area Code Phone Number
Insured’s Employer:
Employer Phone #:

Area Code Phone Number
Patient Dental and Medical History
Name of Previous Dentist and Location:
Date of Last Dental Visit:

Month Day Year
Date
How many times a week do you floss?
How many times a day do you brush?
Would you like your teeth whiter?
Do you like your smile?
Please select “Yes” or “No” to indicate if you have had any of the following:
Gums swollen or tender

Yes No
Grinding your teeth

Yes No
Lip or Cheek or Tongue biting

Yes No
Sores/Growths in your mouth

Yes No
Bad breath

Yes No
Jaw Pain

Yes No
Periodontal Treatment

Yes No
Loose teeth or broken fillings

Yes No
Bleeding gums

Yes No
Sensitivity to sweets

Yes No
Blisters on Lip or Mouth

Yes No
Sensitivity to heat / cold

Yes No
Clicking or popping jaw

Yes No
Sensitivity when biting

Yes No
Dry mouth

Yes No
Burning sensation on tongue

Yes No
Food collection between teeth

Yes No
Trauma in mouth

Yes No
Anxiety

Yes No
Physician’s Name
Phone #:

Area Code Phone Number
Last Visit Date:

Month Day Year
Date
Pharmacy Name:
Phone Number

Area Code Phone Number
*Women:
Are you pregnant?

Yes No
Are you nursing?

Yes No
Are you taking Birth Control Pills?

Yes No
Please select if you are allergic to or had any reactions to:

Ampicillin Aspirin/Ibuprofen Augmentin Latex Codeine Sulfa Percocet Morphine Local Anesthetic Penicillin Tetracycline ANY Metals
Please list any other allergies you may have:
Are you taking blood thinners?

Yes No
Baby Aspirin?

Yes No
How often?
Do you need to take antibiotics prior to dental appointments?

Yes No
Have you used bisphosphonate medications such as Actonel, Fosamax or Zometa within the past 12 years?

Yes No
Are you currently taking any prescription or non-prescription medications (If yes, please list):
Please select “Yes” or “No” to indicate if you have had any of the following:
ADHD

Yes No
Circulatory problems

Yes No
Liver Disease

Yes No
AIDS/HIV

Yes No
Cortisone Treatments

Yes No
Mitral Valve Prolapse

Yes No
Allergies (seasonal)

Yes No
Cough (persistent/bloody)

Yes No
Nervous problems

Yes No
Anemia

Yes No
Diabetes

Yes No
Pacemaker

Yes No
Arthritis

Yes No
Epilepsy

Yes No
Psychiatric care

Yes No
Artificial Heart Valves

Yes No
Fainting or Dizziness

Yes No
Radiation Treatments

Yes No
Artificial Joints

Yes No
Glaucoma

Yes No
Respiratory problems

Yes No
Asthma

Yes No
Headaches

Yes No
Scarlet Fever

Yes No
Back Problems

Yes No
Heart Murmur

Yes No
Shortness of breath

Yes No
Bleeding abnormally with extractions of surgery

Yes No
Heart problems

Yes No
Skin rash

Yes No
Hemophilia

Yes No
Stroke

Yes No
Blood disease

Yes No
Hepatitis

Yes No
Thyroid problems

Yes No
Cancer

Yes No
Herpes

Yes No
Tobacco habit

Yes No
Chemical dependency

Yes No
High Blood Pressure

Yes No
Tuberculosis

Yes No
Chemotherapy

Yes No
Kidney Disease

Yes No
Ulcers

Yes No
Describe any conditions not listed above:
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 to release any information including diagnosis and records of my 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 authorize and request my insurance company to pay directly to the dentist any insurance benefits otherwise payable to me. I understand that my insurance carrier may pay less than the actual bill for services and agree to be responsible for payment of all services rendered on my behalf or my dependents. In the event that I seek credit from the dental office, I consent to release a copy of my credit report to the dental office.
Signature of Patient:
Signature of Doctor:
Should be Empty:

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