Gentledentistrysgv.com - New Patient Registration

New Patient Registration

Please note that it is important to fill in all the fields before submitting. Thank you.
About you
Title*

MrMrsMsDr
Name*

First NameMiddle NameLast Name
I prefer to be called*
Your Birthday*

MonthDayYear
Date
Age*
Sex*

MaleFemale
Social Security Number
Home Address*

Street Address

City

State / ProvincePostal / Zip Code

Apt.#
Email Address*
example@example.com
Marital status*

SingleMarriedPartneredDivorced/SeparatedWidowed
Work Phone

Area CodePhone Number
Home Phone

Area CodePhone Number
Cell Phone*

Area CodePhone Number
Driver’s License Number
Employer*
How long there ?
Occupation
Employer Address*

Address

City

State / ProvincePostal / Zip Code

Apt.#
How did you hear about us?*
Whom may we thank for referring you?*
Where & when are best times to reach you?*
Other family members seen by us*
Previous Dentist*
Present Dentist*
Person responsible for account*
Spouse information
His / Her Name

First NameLast Name
Birthday

MonthDayYear
Date
Employer
Social Security Number
Driver’s License Number
Telephone Work

Area CodePhone Number
Emergency contact information for patient in case of an emergency
His / Her Name*

First NameLast Name
Relationship*
Home Telephone*

Area CodePhone Number
Work Telephone

Area CodePhone Number
Insurance Information
Primary insurance
Dental Coverage?*

yesNo
Insurance Company Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Group Number (Plan, Local or Policy Number)
Insured’s Name
Relationship
Birthday

MonthDayYear
Date
Social Security Number
Insured’s Employer
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have secondary insurance*

YesNo
Dental Coverage?*

yesNo
Insurance Company Name
Address

Street Address

City

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Group Number (Plan, Local or Policy Number)
Insured’s Name
Relationship
Birthday

MonthDayYear
Date
Social Security Number
Insured’s Employer
Address

Street Address

City

CityState

Postal / Zip Code
Medical History
Do you have a personal physician?*

YesNo
Physician’s Name*
Telephone Home

Area CodePhone Number
Date of last visit

MonthDayYear
Date
Your current physical health is*

GoodFairPoor
Describe*
Are you currently under the care of a physician?*

YesNo
Please Explain*
Do you smoke or use tobacco in any other form?*

YesNo
Have you had any metal rods, pins or implants?*

YesNo
Are you taking any prescription or over-the-counter drugs?*

YesNo
Have you ever taken Fosamax, or any other bisphosphonate*

YesNo
Do you wear a cardiac pacemaker, or have you had heart surgery?*

YesNo
Are you required to take any medication before your dental visit?*

YesNo
Are you using a prescribed method of birth control?*

YesNo
Are you pregnant?*

YesNo
Week #*
Are you nursing?*

YesNo
Have you ever had any of the following diseases or medical problems

Abnormal Bleeding / HemophiliaAIDS related complexAlcohol / Drug abuseAnemiaArthritisArtificial bones / Joints / ValvesAsthmaBlood transfusionChemotherapy (Cancer, leukemia)ColitisCongenital heart defectDiabetesDifficulty breathingEmphysemaEpilepsy / seizuresExcessive bleedingRespiratory diseaseArtificial prosthesisCongenital heart diseaseX-Ray or cobalt treatmentFainting spells / seizuresFrequent headachesGlaucomaHay feverHeart attack / surgeryHeart murmurHepatitis / jaundiceHerpes / fever blistersHigh blood pressureAllergies or HivesHospitalized for any reasonKidney diseaseLiver diseaseLupusAngina pectorisCerebral palsyJoint replacementNervous disorderTumors or growthsMitral valve prolapsePacemakerPsychiatric treatmentRadiation treatmentRheumatic / Scarlet feverShinglesSickle cell disease / TraitsSinus problemsStrokeThyroid problemsTuberculosis (TB)UlcersTonsillitisHead injuriesHeart failureChicken poxBlood diseaseDrug addiction
Do you have any serious medical condition(s) that you have ever had?*

YesNo
If "Yes" Please List*
Are you allergic to any of the following?

AspirinPenicillinJewelry / MetalsAnesthetic (Novocain, etc.)Dental anestheticsErythromycinSulfa drugsCodeineTetracyclineLatexOther
Please List Other Allergic*
Do you have any other drugs / Materials that you are allergic to?*

YesNo
If "Yes" Please List*
Dental history
Why have you come to the dentist today?*
Are you currently in pain?*

YesNo
Do you require antibiotics before dental treatment?*

YesNo
Your current dental health is*

GoodFairPoor
Describe*
Do you floss daily?*

YesNo
Type of bristles on your toothbrush?*

HardMediumSoft
Brush Daily?*

YesNo
Have you ever had gum treatment?*

YesNo
Do your gums ever bleed?*

YesNo
Ever Itch?*

YesNo
Have you ever had periodontal disease?*

YesNo
Have you ever had a serious/difficult problem associated with any previous dental work?*

YesNo
Describe*
Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ/TMD)?*

YesNo
Are your teeth sensitive to

HeatCold
Do you have Anything else?*

YesNo
Describe*
Do you have any loose teeth?*

YesNo
Do you still have wisdom teeth?*

YesNo
Are you happy with the way your smile looks?*

YesNo
If not, what would you change?*
Whiter Teeth?*

YesNo
Would you like a fresher breath?*

YesNo
*

I consent to making of videotapes, photographs, and x-rays before, during, and after treatment, and to use the same by the doctor for scientific papers, promotional purposes or demonstrations.
*

The information and health history and preceding answers are true and correct to the best of my knowledge. I authorize and give consent to perform dental services agreed between doctor and patient and/or guardian to be necessary or advisable, including the use of local anesthesia and other medications as indicated. I agree that, regardless of insurance coverage, I am responsible for payment for services rendered. If I ever have any changes in my health or if my medication change I will, without fail, inform the doctor at my next appointment.
Signature
Patients Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty: