PATIENT REGISTRATION
1513 W Dallas St., Ste. 100 | Houston, Texas 77019 | 713.790.0288
Name
First Name
Middle Initial
Last Name
Preferred Name
Patient is
Policy Holder
Responsible Party (if someone other than the patient):
Name
First Name
Middle Initial
Last Name
Address
Address 2
City, State, Zip Code
Home Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Ext
Cellular
Format: (000) 000-0000.
Birth Date
/
Month
/
Day
Year
Date
Social Security No.
Driver's Licence #
Responsible Party is
Policy Holder for Patient
Primary Insurance Policy Holder
Secondary Insurance Policy Holder
Patient Information
Section 1
Address
Address 2
City
State
Zip Code
Home Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Ext
Cellular
Format: (000) 000-0000.
Sex
Male
Female
Marital Status
Married
Single
Divorced
Separated
Widowed
Birth Date
/
Month
/
Day
Year
Date
Age
Social Security No.
Driver's Licence #
E-mail address
example@example.com
I would like to receive correspondence via e-mail.
Patient Information
Section 2
Employment Status
Full Time
Part Time
Retired
Unemployed
Student Status
Full Time
Part Time
None
Employer ID
Carrier ID
Preferred Dentist
Preferred Pharmacy
Preferred Hygienist
Patient Information
Section 3
Previous Dentist
Emergency Contact
Emergency Contact #
PreMed Necessary?
Primary Dental Insurance Information
Please enter all information for us to verify your insurance
Name of Insured
Relationship to Insured
Self
Spouse
Child
Other
Insured Social Security No.
Insured Birth Date
/
Month
/
Day
Year
Date
Employer
Address
Address
Address 2
City, State, Zip
State / Province
Postal / Zip Code
Insurance Company
Address
Address
Address 2
City, State, Zip
State / Province
Postal / Zip Code
Remaining Benefits
Remaining Deductible
Secondary Dental Insurance Information
If you do not have a secondary insurance, please leave blank
Name of Insured
Relationship to Insured
Self
Spouse
Child
Other
Insured Social Security No.
Insured Birth Date
/
Month
/
Day
Year
Date
Employer
Insurance Company
Address
Address
Address 2
City, State, Zip
State / Province
Postal / Zip Code
Remaining. Benefits
Remaining Deductible
Please upload a copy a copy of your Driver's License/ID
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Address
Address
Address 2
City, State, Zip
State / Province
Postal / Zip Code
MEDICAL & DENTAL HISTORY
1513 W Dallas St., Ste. 100 | Houston, Texas 77019 | 713.790.0288
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.
Patient Name
Date of Birth
/
Month
/
Day
Year
Date
Are you under a physician's care now?
Yes
No
If Yes, please explain
Have you been hospitalized, had surgery, or anesthesia?
Yes
No
If Yes, please explain
History or family history of problems with anesthesia?
Yes
No
If Yes, please explain
Have you ever had a serious head or neck injury?
Yes
No
If Yes, please explain
Are you taking any medications, pills, or drugs?
Yes
No
If Yes, please list each med. If you have a meds list, you can upload it in the next section.
Do you use tobacco?
Yes
No
Packs per day
# of years
Do you drink alcohol?
Yes
No
Drinks per week
Do you use recreational drugs?
Yes
No
Are you on a special diet?
Yes
No
If Yes, please explain
What do you take for headaches or pain?
Ex: Tylenol, Aspririn
Women: Are you pregnant/trying to get pregnant?
Yes
No
Women: Are you taking oral contraceptives?
Yes
No
Women: Are you nursing?
Yes
No
Are you allergic to any of the following?
Aspirin
Penicillin
Codeine
Acrylic
Metal
Latex
Local Anesthetics
Other
Do you have, or have had, any of the following?
AIDS/HIV Positive
Anaphylaxis
Anemia
Arthritis/Rheumatism
Artificial Heart Valve
Artificial Joint
Asthma
Back Pain
Blood Transfusion
Breathing Problem
Bruise Easily
Cancer
Chemotherapy
Chest Pains
Cold Sores/Fever Blisters
Congenital Heart Disorder
Cortisone Medicine
Depression
Diabetes
Drug Addiction
Easily Winded
Emphysema
Epilepsy or Seizures
Excessive Bleeding
Excessive Thirst
Fainting/Dizziness
Frequent Cough
Frequent Diarrhea
Frequent Headaches
Glaucoma
Heart Attack/Failure
Heart Murmur
Heart Pace Maker
Heart Trouble/Disease
Hemophilia
Hepatitis A
Hepatitis B or C
Herpes
High Blood Pressure
Hives or Rash
Hypoglycemia
Irregular Heartbeat
Kidney Problems
Leukemia
Liver Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse
Parathyroid Disease
Psychiatric Treatment
Radiation Treatments
Recent Weight Loss
Renal Dialysis
Rheumatic Fever
Seasonal Allergies
Shingles
Sickle Cell Disease
Sinus Trouble
Sleep Apnea
Snoring
Stomach/Intestinal Disease
Stroke
Swelling of Limbs
Thyroid Disease
Tonsilitis
Tuberculosis
Tumors/Swelling
Ulcers
Venereal Disease
Have you ever had any serious illness not listed above?
If yes, please explain
Dental History
What is your Chief Complaint?
Who is your Dentist?
Date of last dental cleaning?
/
Month
/
Day
Year
Date
Have you ever had periodontal care?
Yes
No
If Yes, when?
Have you ever had orthodontic care?
Yes
No
If Yes, when?
How often do you brush your teeth?
How often do you floss your teeth?
Have you ever experienced any of the following?
Bleeding gums
Painful gums
Receding gums
Puss
Loose teeth
Spaces between teeth
Drifting of teeth
Bad breath
Dry mouth
Pain in jaw
Clicking in jaws
Grinding teeth
Clenching teeth
Are any of your teeth sensitive to hot or cold, or when chewing?
Yes
No
If Yes, please explain
How would you describe your previous dental experiences?
Are you aware that recent research has suggested that infected gums may increase the dangers associated with diabetes, heart disease, stroke, lung damage, and/or (a female) delivering a premature/low-birth-weight baby?
Yes
No
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my resposibility to inform the dental office of any changes in medical status.
Signature of Patient, Parent, or Guardian
*
Date
*
-
Month
-
Day
Year
Today's date
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ADDITIONAL INFORMATION
1513 W Dallas St., Ste. 100 | Houston, Texas 77019 | 713.790.0288
Dental Insurance
We are happy to help you obtain your dental insurance benefits and will assist you in filing your claims. Please send us a copy of your dental insurance card (front and back) ahead of time by uploading it below.
Meds List
If you have a medications list you'd like to share with us, please upload it below.
If neither is applicable, bypass this page and finalize your paperwork by clicking "Submit".
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