Patient Registration Form

Patient Registration
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number (Cell) *

Area Code Phone Number
Phone Number (Home) *

Area Code Phone Number
Phone Number (Work)

Area Code Phone Number
Email *
example@example.com
Employer
Occupation
Dental Insurance Company (If applicable)
Plan/Policy Number
ID/Certificate #
Person Responsible For Account (Name, Address, Home Phone, Business Phone)
Preferred Method of Payment (Cash and cheques are no longer options) *

Debit VISA Mastercard
How did you learn about our office? *

Referral Website Location Mall Advertising
We appreciate referrals. Whom may we thank for referring you?

First Name Last Name
Emergency Contact Info
Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Relationship to Patient *
Medical Information
Previous/Current Dentist (name and number) *
Date of last Xrays *
Current Physician (name and number) *
Medical History
Do you have any of the following diseases or problems? *

Cough persistent for more than 3 weeks? Cough that produces blood? Active tuberculosis? Been exposed to anyone with tuberculosis? No I do not
Are you under the care of a physician? *

Yes No
If yes, include name, address, phone number and reason.
For women: Are you pregnant?

Yes No
If so, how many weeks are you into your pregnancy?
For women: Are you presently breastfeeding?

Yes No
Are you in good health? *

Yes No
Have there been any changes in your health in the past year? *

Yes No
If yes, please explain.
Date of last physical exam? *
Have you been hospitalized in the past 5 years? *

Yes No
If yes, list reason and date.
Please list all prescription and over the counter medications including name, dosage, purpose and time of day taken. *
Are you fearful of dental treatment? *

No Yes Yes and I would like to discuss sedation (being put asleep)
Do you use controlled substances (drugs)? *

No Yes Yes; Prescribed by a physician
If yes, which ones?
Do you use tobacco? *

Yes No
If yes, what kind? How often?
Do you drink alcohol? *

Yes No
If yes, how many drinks in last 24 hours? How many per week?
Have you had an orthopedic total joint (hip, knee, elbow, finger, etc) replacement? *

Yes No
If yes, include date, type of replacement and any complications.
Provide orthopedic surgeon's name and number.
Are you taking or planning to take an antiresorptive agent (such as Fosamax, Actonel, Boniva, Reclast, and Prolia)? *

Yes No
If yes, what type, dosage and when was it taken?
Since 2001, have you or will you be treated with an antiresorptive agent (Aredia, Zometa, XGEVA)? *

Yes No
If yes, what type, dosage and when was it taken?
For which condition?

Bone pain Paget’s disease Multiple myeloma Metastatic cancer
Are you?

Taking birth control or hormone replacement Nursing Pregnant or trying to get pregnant
Are you allergic to or had a reaction to the following?

Latex Codeine or other narcotics Penicillin or other antibiotics Sulfa drugs Barbiturates Local anesthetics Metals Hay fever Food Iodine Animals Pine nuts
If yes to any please specify type and reaction.
Please indicate if you have or have had any of the following diseases or problems.

Cardiovascular disease Congestive heart failure Low blood pressure Mitral valve prolapse Rheumatic heart disease Blood transfusion Arthritis Systemic lupus erythematous Emphysema Chest pain upon exertion Eating disorder GI reflux/ persistent heart burn Angina Heart attack High blood pressure Pacemaker Abnormal bleeding Hemophilia Autoimmune disease Asthma Sinus trouble Chronic pain Malnutrition Ulcers Arteriosclerosis Heart murmur Other Congenital Heart Defect (CHD) Rheumatic fever Anemia AIDS/HIV Rheumatoid arthritis Bronchitis Cancer/chemotherapy/radiation Diabetes Type 1 (Insulin-Dependent) or Type 2 (Non Insulin-Dependent) Gastrointestinal disease Thyroid problem Stroke Epilepsy Sleep disorder Recurrent infection Osteoporosis Severe or rapid weight loss Glaucoma Fainting spells or seizures Snoring Kidney problems/dialysis Persistent swollen glands in neck Sexually transmitted disease Damaged heart valves Hepatitis, jaundice or ulcers Neurological disorder Mental health disorder Night sweats Severe headaches/ migraines Excessive urination Herpes, cold sores, fever blisters
If yes to any, list dates, kinds, controlled or uncontrolled
If yes to any of the following Congenital Heart Defect (CHD) conditions, antibiotic prophylaxis is recommended prior to all invasive dental treatments. Please consult your physician.

Artificial (prosthetic) valve Previous infective endocarditis Damaged valves in transplanted heart CHD; unrepaired cyanotic CHD CHD; repaired completely in last 6 months CHD; repaired with residual defects
Has a physician or dentist recommended that you take antibiotics prior to dental treatment? *

Yes No
Do you have any diseases or problems not listed above that you think we should know about? *

Yes No
If yes, what?
Dental History
Are you experiencing any discomfort at this time? *

No Yes
If yes, please specify
Do your gums feel tender, swollen, or bleed easily? *

No Yes
Are you aware of any lump or swelling in your mouth? *

No Yes
Grind your teeth? *

Present Past Never
Bite your cheek? *

Present Past Never
Tongue thrust? *

Present Past Never
Mouth breather? *

Present Past Never
Bulimic/ anorexic? *

Present Past Never
Cigar/cigarette? *

Present Past Never
Vape? *

Present Past Never
Hookah (water pipe)? *

Present Past Never
Pipe? *

Present Past Never
Bite nails? *

Present Past Never
Smokeless tobacco? *

Present Past Never
Suck your thumb/finger? *

Present Past Never
Use a toothpick or stimulator? *

Present Past Never
Use chewing gum? *

Present Past Never
Eat candy? *

Present Past Never
Drink soft drinks? *

Present Past Never
If present or past to any, please list when, how often and what kind if applicable.
How often do you brush? When? Electric or manual toothbrush? *
How often do you floss? When? *
Do you use mouthwash? What type? *
Other types of oral health instruments ? *
Personal or family history of oral cancers? *

Yes No High risk
Are you currently experiencing pain in your mouth? *

Yes No
If yes, where at, what type and for how long?
Are your teeth sensitive to hot/cold *

Present Past Never
Are your teeth sensitive to biting or chewing? *

Present Past Never
Are your teeth sensitive to sweets? *

Present Past Never
If present or past to any, please explain.
Have you ever had orthodontic treatment? Braces or Invisalign? *

Present Past Never
If present or past to any, please explain.
Are you interested in Orthodontics Treatment? *

No Yes
If interested in orthodontic treatment, please state what you would change about the appearance of your teeth.
Any TMJ issues *

No Yes in the past Yes presently WITHOUT discomfort Yes presently WITH discomfort
If yes WITH discomfort, please specify:
Have you had a bite splint / nightguard? *

Present Past Never No, but it was recommended to me by a dentist
Have you had periodontal treatment? *

Present Past Never
Have you had maxillofacial surgery? *

Present Past Never
Have you had a serious injury to your mouth or head? *

Present Past Never
Do you participate in contact sports? *

No Yes
Do you have a Sportsguard? *

No Yes (custom-fitted) Yes (over-the-counter)
Normal frequency for dental hygiene appointments? (Ex. Every 6 mo) *
Date of last dental appointment? *
Any complications from dental treatment? *

To the best of my knowledge, the above information is correct. I *

First Name Last Name
consent TO THE PERFORMING OF THE DENTAL PROCEDURES AGREED TO BE NECESSARY OR ADVISABLE FOR MYSELF OR *

First Name Last Name
AND I WILL ASSUME RESPONSIBILITY FOR FEES ASSOCIATED WITH THESE PROCEDURES. I AUTHORIZE RELEASE, TO MY INSURER/PLAN ADMINISTRATOR, THEINFORMATION CONTAINED IN CLAIMS AND ESTIMATES MAILED OR SUBMITTED ELECTRONICALLY. In accordance with Privacy Legislation, for appointment scheduling/confirmation, you have my permission to speak with *

First Name Last Name
Relationship
Patient/Parent/Guardian SIGNATURE *

Please use your mouse or track pad cursor. (On mobile devices, please use your finger). Clear
Date *

Month Day Year
Date
Reserved appointments that are not cancelled by telephone 24 business hours prior to the scheduled time will be subject to a missed appointment fee.
Should be Empty:

Patient Registration

Emergency Contact Info

Medical Information

Medical History

Dental History