New Patient Registration

  • New Patient Registration Form

    Welcome to Aesthetic Smiles! We look forward to providing excellent dental care to you and your family. Our goal is to help you look and feel your absolute best through comprehensive dental care.
  • Date of Birth*
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  • Gender*
  • Marital Status*
  • Preferred Method of Contact*
  • Method of Payment*

  • Emergency Contact Info

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  • HIPAA AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION

    I authorize Aesthetic Smiles to discuss or disclose my entire medical and dental records (including financials) with the following persons. I understand that I have the right to revoke this authorization, in writing, at any time, except where uses or disclosures have already been made based upon my original permission. I may not be able to revoke this authorization if its purpose was to obtain insurance. In order to revoke this authorization, I must do so in writing and send it to the appropriate disclosing party. I understand that uses and disclosures already made based upon my original permission cannot be taken back. I understand that it is possible that information used or disclosed with my permission may be re-disclosed by the recipient and is no longer protected by the HIPAA Privacy Standards. I understand that treatment by any party may not be conditioned upon my signing of this authorization and that I may have the right to refuse to sign this authorization.
  • Date
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  • Insurance Information

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  • Employee’s (Subscriber) Date of Birth
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  • Medical Insurance

    (If applicable)
  • Date of Birth
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  • Financial Agreement

  • Date*
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  • Medical History

  • Do you have any of the following diseases or problems?*
  • Do you have a current MD or PCP?*
  • Are you in good health?*
  • Have there been any changes in your health in the past year?*
  • Have you been hospitalized in the past 5 years?*
  • Do you wear contact lenses?*
  • Do you have pets?*
  • Do you use controlled substances (drugs)?*
  • Do you use tobacco?*
  • Do you drink alcohol?*
  • How interested are you in stopping drugs, alcohol or tobacco use?*
  • Have you had an orthopedic total joint (hip, knee, elbow, finger, etc) replacement?*
  • Do you need prophylactic antibiotic treatment before dental treatment?*
  • Are you taking or planning to take an antiresorptive agent (such as Fosamax, Actonel, Boniva, Reclast, and Prolia)?*
  • Since 2001, have you or will you be treated with an antiresorptive agent (Aredia, Zometa, XGEVA)?*
  • For which condition?

  • For Women Only. Are you:
  • Are you allergic to or had a reaction to the following?*

  • Please indicate if you have or have had any of the following diseases or problems.*

  • Do you have any of the following CHD conditions? If yes, antibioticprophylaxis is recommended. Consult physician.
  • Has a physician or dentist recommended that you take antibiotics prior to dental treatment?*
  • Do you have any diseases or problems not listed above that you think I should know about?*
  • Do you have a family history of any of the following medical issues?*

  • TMJ Evaluation

  • Do you have any of the following?*

  • Dental History

  • Do you grind your teeth?*
  • Do you bite your cheek?*
  • Do you have a tongue thrust?*
  • Are you a mouth breather?*
  • Are you bulimic/ anorexic?*
  • Do you smoke cigars/cigarettes?*
  • Do you use a pipe?*
  • Do you bite your nails?*
  • Do you use smokeless tobacco?*
  • Do you suck your thumb/finger?*
  • Do you use a toothpick or stimulator?*
  • Do you use chewing gum?*
  • Do you eat candy?*
  • Do you drink soft drinks?*
  • Personal or family history of oral cancers?*
  • Are you currently experiencing pain in your mouth?*
  • Are your teeth sensitive to hot/cold*
  • Are your teeth sensitive to biting or chewing?*
  • Are your teeth sensitive to sweets?*
  • Have you ever had orthodontic treatment?*
  • Have you had a bite plate / guard?*
  • Have you had periodontic treatment?*
  • Have you had oral surgery?*
  • Have you had a serious injury to your mouth or head?*

  • Sleep & Airway Evaluation

  • Please check any of the following symptoms that you currently experience.*

  • Privacy Policy

  • Date*
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  • Should be Empty: