New Patient Registration
Patient Name
*
First Name
Middle Name
Last Name
I prefer to be called
Birthday
*
-
Month
-
Day
Year
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Age
Gender
*
Please Select
Male
Female
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
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Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
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Mississippi
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Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
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Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code / Apt
Email Address
*
example@example.com
Home Phone Number
*
Please enter a valid phone number.
Social Security Number
How did you hear about us?
Please Select
Internet
Search Engine
Facebook
Twitter
Yellow Pages
Newspaper
Postcard / Flyer
Referral
Whom may we Thank for referring you?
Other family members seen by us
Previous Dentist's Name
Dentist Phone Number
Please enter a valid phone number.
Dentist Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code / Apt
Adult Patient Details
Marital Status
Please Select
Single
Married
Partnered
Divorced/Separated
Widowed
Cell Phone Number
*
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Driver’s License Number
Where & when are best times to reach you?
Spouse's Name
Employer Details
Employer
Occupation
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code / Apt
Relative or friend not living with you
His / Her Name
Relationship
Work Phone Number
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Insurance Information
Primary Insurance
Dental Coverage?
Yes
No
Insurance Co. Name
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code / Apt
Phone Number
Please enter a valid phone number.
Group# (Plan, Local or Policy#)
Insured’s Name
Birthday
-
Month
-
Day
Year
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Social Security Number
Do you have secondary insurance?
*
Yes
No
Secondary Insurance
Dental Coverage?
Yes
No
Insurance Co. Name
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code / Apt
Phone Number
Please enter a valid phone number.
Group# (Plan, Local or Policy#)
Insured’s Name
Birthday
-
Month
-
Day
Year
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Social Security #
Dental History
Why have you come to the dentist today?
Date of last dental visit
-
Month
-
Day
Year
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Last dental cleaning
-
Month
-
Day
Year
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Last full mouth X-rays
-
Month
-
Day
Year
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Do you have or have you ever had
Dental complaints/problem?
*
Yes
No
Growth or sore spots in your mouth?
*
Yes
No
Difficult extractions in the past?
*
Yes
No
Prolonged bleeding after extraction?
*
Yes
No
Wisdom teeth extracted?
*
Yes
No
Periodontal surgery?
*
Yes
No
Bleeding gums?
*
Yes
No
Are you in pain now?
*
Yes
No
Low back pain?
*
Yes
No
Pain in or near your ears/jaw?
*
Yes
No
Loose or sensitive teeth?
*
Yes
No
Which side?
*
Chronic headaches, neck or shoulder pain?
*
Yes
No
A clicking jaw?
*
Yes
No
*
Sometimes
Always
Bleaching, either at home or by a dentist?
*
Yes
No
*
Home
Dentist
Unhealed injuries or inflammations in or around your mouth?
*
Yes
No
“Trench mouth” or other gum conditions?
*
Yes
No
Reaction to anesthetic (i.e. Novacaine)?
*
Yes
No
Mouth sensitivity to pressure or irritants(i.e. cold, sweets, etc.)?
*
Yes
No
Removable/fixed dentures or other appliances?
*
Yes
No
Instruction on the correct method of brushing your teeth?
*
Yes
No
Instruction on the care of your gums?
*
Yes
No
Do you chew on one side of your mouth?
Yes
No
If "Yes"
*
Left
Right
Do you clench, grind or brux (gnash) your teeth?
*
Yes
No
Does any part of your mouth hurt when clenched?
*
Yes
No
Do your teeth and/or jaws ever feel “tired” when you wake up?
*
Yes
No
Do you have now, or have you ever had pain in your jaw or in the sides of your face about your ears?
*
Yes
No
Have you ever had partial or full-mouth orthodontic treatment?
*
Yes
No
Has antibiotic pre-medication prior to dental work ever been advised by your physician?
*
Yes
No
DO YOU SNORE WHEN SLEEPING?
*
Yes
No
Have you ever had problems with prior dental treatment?
*
Yes
No
Explain
*
Medical History
Do you have a personal physician?
*
Yes
No
Physician’s Name
Telephone Number
Please enter a valid phone number.
Date of last medical exam
-
Month
-
Day
Year
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Your current physical health is
*
Good
Fair
Poor
Has there been a change in your health within the last year?
*
Yes
No
Have you been hospitalized or had a serious illness in the last three years?
*
Yes
No
Why
*
Are you currently under the care of a physician?
*
Yes
No
Explain
*
Have you experienced
Chest pain (angina)?
*
Yes
No
Sinus problems?
*
Yes
No
Blurred vision?
*
Yes
No
Swollen ankles?
*
Yes
No
Difficulty swallowing?
*
Yes
No
Seizures?
*
Yes
No
Shortness of breath?
*
Yes
No
Frequent vomiting or nausea?
*
Yes
No
Jaundice?
*
Yes
No
Recent weight loss, fever or night sweats?
*
Yes
No
Dizziness?
*
Yes
No
Excessive thirst?
*
Yes
No
Persistent cough or coughing up blood?
*
Yes
No
Ringing in ears?
*
Yes
No
Dry mouth?
*
Yes
No
Bleeding problems or bruising easily?
*
Yes
No
Headaches?
*
Yes
No
Frequent urination?
*
Yes
No
Joint pain or stiffness?
*
Yes
No
Fainting spells?
*
Yes
No
Mood swings?
*
Yes
No
For Women
Are you taking any oral contraceptives or other hormonal therapy?
*
Yes
No
Are you pregnant?
*
Yes
No
Week #
*
Obstetrician Name
Are you nursing?
*
Yes
No
Do you have or have you had.
*
Heart disease
AIDS or ARC
Prosthetic heart valve
Heart attack or heart defects
HIV positive
Artificial joint
Heart murmurs
Tumor or cancer
Blood transfusions
Rheumatic fever
Skin diseases
Psychiatric care
Pacemaker
Anemia
Emotional disorder
Stroke or hardening of arteries
Venereal disease
Kidney/bladder disease
High blood pressure
Herpes
Arthritis
Chemotherapy and/or Radiation
Contact lenses
Family history of heart disease
Implants
Stomach problems or ulcers
Eye disease
Family history of diabetes or tumors
Hospitalization
Thyroid or adrenal disease
Hepatitis or other liver diseases
Surgeries
Diabetes
TB, asthma, emphysema, or lung disease
treatment for osteoporosis?
Bisphosphonate drugs (Fosamax®, Aredia®, Zometa®, Actonel®, Boniva®)
None
When?
*
Do you have any serious medical conditions?
*
Yes
No
If "Yes" List
*
Are you taking or have you taken
*
Recreational drugs
Tobacco (in any form)
Alcohol
Bisphosphonates (IV, etc.)
Drug dependent
Dietary/Herbal supplements
Abused drugs
Latex allergies
Drugs such as fen-phen for weight loss
Drugs. Medicines (incl. aspirin)
None
Please List
*
Does any action have allergic?
*
Yes
No
If "Yes" please list here
*
Responsibility and Consent Statement
*
To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication. I certify that I have read and understood the above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my dentist or any other member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. The undersigned hereby authorizes Doctor to initiate a collection of records for my comprehensive exam, consisting of radiographs, study models, photographs, or any other diagnostic aids deemed appropriate by the Doctor to make a thorough diagnosis of the patient’s dental needs. I also authorize the Doctor to perform any and all forms of treatment, medication, and therapy that may be indicated in connection with the patient named on this form and further authorize and consent that Doctor choose and employ such assistance as he deems fit. I also understand the use of anesthetic agents embodies a certain risk. I understand the responsibility for payment for Dental Services provided in this office for myself, or my dependents are mine, due and payable at the time services are rendered regardless of insurance coverage. I agree that Doctor’s office will assist me in submitting all insurance claims as a courtesy only and that one claim per patient per visit will be submitted to my insurance carrier at no cost. I further acknowledge that any insurance coverage that I may have is an agreement between my insurance company, myself, and/or my employer. I understand that a service charge of 1% per month (12% APR) is incurred on any unpaid balance after 30 days from the date the service was provided. If my account is referred for collection, I will be responsible for any attorney’s fees and court costs necessary to collect the unpaid balance.
Signature
*
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Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
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