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.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Non-Binary
Marital Status
*
Single
Married
Separated
Divorced
Widowed
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number
*
Email
*
example@example.com
Preferred Method of Contact
*
Text
Call
Email
Method of Payment
*
Insurance
Cash/Check
Credit Card
Purpose of Today's Visit
*
How did you hear about Aesthetic Smiles?
Emergency Contact Info
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Relationship to Patient
*
Back
Next
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.
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Signature
Clear
Back
Next
Insurance Information
Primary Insurance Company (Dental)
Primary Claims Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
ID or Member #
Group or Local #
Insured Social Security #
*
Primary Insurance Phone #
-
Area Code
Phone Number
Employer
*
Employee's Name
Employee’s (Subscriber) Date of Birth
-
Month
-
Day
Year
Date
Years with Company
Medical Insurance
(If applicable)
Medical Insurance Company
Medical Claims Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
ID or Member #
Group or Local #
Insured Social Security #
Date of Birth
-
Month
-
Day
Year
Date
Medical Insurance Phone #
-
Area Code
Phone Number
Employer
Employee's Name
Years with Company
Financial Agreement
I have read and agree to the terms and conditions described in the Financial Agreement.
*
Clear
Date
*
-
Month
-
Day
Year
Date
Back
Next
Medical History
Do you have any of the following diseases or problems?
*
Active tuberculosis
Persistent cough greater than 3 weeks
Cough that produces blood
Been exposed to anyone with tuberculosis
N/A
Do you have a current MD or PCP?
*
Yes
No
If yes, include name, address, phone number and reason.
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?
*
Height:
Weight:
Have you been hospitalized in the past 5 years?
*
Yes
No
Have you had your tonsils removed?
*
If yes, list reason and date.
Please list all prescription and over the counter medications including name, dosage, purpose and time of day taken.
*
Do you wear contact lenses?
*
Yes
No
Do you have pets?
*
Yes
No
If yes, how many? What type of pet? Do they sleep in your bedroom?
Do you use controlled substances (drugs)?
*
Yes
No
Type option 4
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?
How interested are you in stopping drugs, alcohol or tobacco use?
*
Very
Somewhat
Not interested
Not applicable
Have you had an orthopedic total joint (hip, knee, elbow, finger, etc) replacement?
*
Yes
No
Do you need prophylactic antibiotic treatment before dental treatment?
*
Yes
No
If yes, include date, type of replacement and any complications.
Provide orthopedic surgeons 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
For Women Only. Are you:
Taking birth control or hormone replacement
Nursing
Pregnant or trying to get pregnant
None of the above
Are you allergic to or had a reaction to the following?
*
Local anesthetics
Barbiturates
Codeine or other narcotics
Latex
Hay fever
Food
Penicillin or other antibiotics
Sulfa drugs
Metals
Iodine
Animals
Not allergic/No allergies
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
Rheumatic fever
Anemia
AIDS/HIV
Rheumatoid arthritis
Bronchitis
Cancer/chemotherapy/radiation
Diabetes 1 or 2
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
None of the above
If yes to any, list dates, kinds, controlled or uncontrolled
Do you have any of the following CHD conditions? If yes, antibioticprophylaxis is recommended. Consult 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 I should know about?
*
Yes
No
If yes, what?
Do you have a family history of any of the following medical issues?
*
High Bllod Pressure
Heart Disease
Stroke
Congestive Heart Failure
Depression
Diabetes
Overweight/Obesity
Snoring
Sleep Apnea
Anxiety
Chronic Insomnia
Restless leg Syndrome
Multiple Sclerosis
Sleep Walking
None of the above
TMJ Evaluation
Do you have any of the following?
*
Pain in jaw
Pain in ear
Pain around eyes
Pain in lower jaw
Pain in upper jaw
Pain in neck
Pain in shoulder
Pain in forehead
Pain in temples
Pain in facial muscles
Facial muscle twitch
Subjective hearing loss
Clicking or popping
Grating sound in joint
Dizziness
Ringing in ears
Fullness/Blockage in ear
Partical inabilty to open mouth
Difficulty chewing or swallowing
Pain in tongue
Difficulty breathing
Constantly tired
Mouth breather at night
Previous injury to face or teeth
Clench or grind teeth
None of the above
If yes to any of the above, please indicate LEFT or RIGHT side here:
Dental History
Do you grind your teeth?
*
Present
Past
Never
Do you bite your cheek?
*
Present
Past
Never
Do you have a tongue thrust?
*
Present
Past
Never
Are you a mouth breather?
*
Present
Past
Never
Are you bulimic/ anorexic?
*
Present
Past
Never
Do you smoke cigars/cigarettes?
*
Present
Past
Never
Do you use a pipe?
*
Present
Past
Never
Do you bite your nails?
*
Present
Past
Never
Do you use smokeless tobacco?
*
Present
Past
Never
Do you suck your thumb/finger?
*
Present
Past
Never
Do you use a toothpick or stimulator?
*
Present
Past
Never
Do you use chewing gum?
*
Present
Past
Never
Do you eat candy?
*
Present
Past
Never
Do you drink soft drinks?
*
Present
Past
Never
How much chocolate do you eat per day?
*
If you drink caffeine, how many cups of coffee, energy drinks, tea or soda do yo drink per day?
If present or past to any, please list when, how often and what kind if applicable.
How often do you brush? When?
*
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?
*
Present
Past
Never
Have you had a bite plate / guard?
*
Present
Past
Never
Have you had periodontic treatment?
*
Present
Past
Never
Have you had oral surgery?
*
Present
Past
Never
Have you had a serious injury to your mouth or head?
*
Present
Past
Never
If present or past to any, please list what, dates, and reasons.
What is your normal schedule for dental cleanings? (Ex. Every 6 mo)
*
Date of last dental appointment?
*
Any complications from dental treatment?
*
Do you participate in sports?
*
Sleep & Airway Evaluation
Please check any of the following symptoms that you currently experience.
*
Loss of appetite
Fever
Fatigue
GERD/Heartburn/Indigestion
Black/Bloody Stool/ Diarrhea
Nausea/Vomiting
Jaundice
Abdominal Pain
Cough
Asthma
Wheezing
Poor Exercise Tolerance
Bedwetting
Frequent Urination
Difficulty Urinating
Blood in Urine
Erectile Dysfunction
Sneezing
Runny Nose
Itchy Eyes/Nose
Hives
Nasal Allergies/Hay Fever
Nasal Congestion
Blurry Vision
Double Vision
Vision Loss
Palpitations
Chest Pain
Daytime Shortness of Breath
Night Time Shortness of Breath
Ankle Swelling
Unusal Moles
Rash
Dryness
Heat Intolerance
Excessive Thirst
Constipation
Cold Inolerance
Cold Hands/Feet
Decreased Libido
Stiff/sore Joints
Muscle Pain
Red or Swollen Joints
TMJ Joint/Jaw Pain
Hearing Loss
Sore Throat
Sinus Congestion
Hoarseness
Weakness
Seizures
Involentary Tongue Biting
Passing Out
Dizziness
Numbness
Headaches
Restless Leg Syndrome
Excessive Stress
memory Loss
Difficulty with Focus
Hallucinations
Nervousness/Anxiety
Depressed Mood
None of the above
Back
Next
Privacy Policy
I have read the Privacy Policy.
*
Clear
Date
*
-
Month
-
Day
Year
Date
Submit
Print Form
Should be Empty: