New Patient Registration Form
Please note that it is important to fill in all the fields before submitting. Thank you.
About You
Title
Please Select
Mr
Mrs
Ms
Dr
Patient Name
*
First Name
Middle Name
Last Name
Your Birthday
*
-
Month
-
Day
Year
Date
Home Address
*
Street Address
APT#
City
State
Post Code
Home Phone
-
Area Code
Phone Number
Cell Phone
*
-
Area Code
Phone Number
Email Address
*
example@example.com
Marital Status
Please Select
Single
Married
Divorced
Widowed
Other
If other please mention
Employer
Employer Address
*
Street Address
APT#
City
State
Post Code
Family Physician
Work Phone
-
Area Code
Phone Number
Cell Phone
*
-
Area Code
Phone Number
Date of Last Medical Exam
-
Month
-
Day
Year
Date
Spouse, Parent, or Guardian Details
His / Her Name
*
Name of Spouse, Parent, or Guardian
Employer
Employer Address
Street Address
APT#
City
State
Post Code
Home Phone
-
Area Code
Phone Number
Phone (Bus) #
-
Area Code
Phone Number
Emergency Contact Details
Contact Name
*
Phone Number
*
-
Area Code
Phone Number
Whom may we thank for referring you to our practice?
Please Select
Web page
Newspaper
Flyer
Yellow Pages
Another Patient
If Another Patient Please Mention
*
Insurance information
Primary Insurance Information
Do you have dental insurance?
*
Yes
No
Name of Insured
Relation to Insured
Date of Birth
-
Month
-
Day
Year
Date
Insurance Company
Group #
ID #
Credit Card Type
Credit Card #
Exp Date
-
Month
-
Day
Year
Date
Do you have Secondary Insurance?
*
Yes
No
Secondary Insurance Information
Do you also fall into another family member’s dental insurance?
*
Yes
No
Name of Insured
Date of Birth
-
Month
-
Day
Year
Date
Insurance Company
Group #
ID #
Authorization
*
I hereby authorize and request my insurance company to pay directly to the dentist for the services rendered. I understand that I am financially responsible for all dental fees, whether or not insurance pays for them. I authorize the use of this signature on all electronic submission of dental insurance claims.
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Medical History
Do you have or ever had any of the following? Please check off those that apply to you.
AIDS/HIV
Anxiety
Artificial joints
Blood disorder
Angina
Diabetes
Asthma
Fainting
Breathing Problems
High Blood Pressure
Cancer
Jaundice
Depression
Liver Disease
Epilepsy
Stomach problems
Heart Disease
Sinus Problems
Heart Murmur
Smoking
Hepatitis
Tumours
Hospitalization
Arthritis
Kidney Disease
Latex Allergy
Mitral Valve Prolapse
Pacemaker
Radiation Txt
Rheumatic Fever
Stroke
Ulcers
Surgery
Thyroid Problems
Pregnant, due on:
Due Date
*
-
Month
-
Day
Year
Date
Are you under the care of a physician?
*
Yes
No
Reason
Are you taking any medications, drugs, supplements, herbs?
*
Yes
No
Please List
Are you allergic to any medications?
*
Yes
No
Please List
*
Other health concerns your dentist should know about
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Dental History
Former Dentist
City
Province
Last Dental Visit
-
Month
-
Day
Year
Date
Last Dental X-rays
-
Month
-
Day
Year
Date
Do you have or ever had any of the following? Please check off those that apply to you
Bad Breath
Bleeding gums
Braces
Clicking Jaw
Dentures
Dry Mouth
Grinding teeth
Gum Surgery
Injury to Jaws
Headaches
Mouth Breathing
Mouth Sores
Tendency to faint
Food trap in teeth
Reaction to Freezing/Local Anesthetic
Sensitivity to
Hot
Cold
Sweets
Chewing
Other conditions
Please List Other Conditions
*
Reason for today’s visit
Have you ever been advised to take antibiotics before dental appointments?
How often do you
*
Brush?
Floss?
City
State / Province
Postal / Zip Code
Have you been seeing a dentist regularly?
*
Yes
No
How do you feel about your smile?
*
If given a choice, what would you like to change about your smile?
Informed Consent to Dental Treatment
*
I have read and answered the questions to the best of my knowledge.
*
I have discussed with the dentist, the risks, benefits and alternative options for my dental treatment including consequences of no treatment. I hereby authorize Dr. Rina M. Kotecha to perform any and all forms of dental treatment, medication and therapy indicated to treat my oral conditions.
Patient/Parent or Guardian Signature
*
Clear
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: