www.smiledesigner.net - New Patient Registration Form

New Patient Registration Form

Please note that it is important to fill in all the fields before submitting. Thank you.
General Information
Patient Name*

First NameMiddle NameLast Name
Your Birthday*

MonthDayYear
Age
Gender*
Social Security Number
Marital Status
Full Time Student?

YesNo
Home Address*
Street Address, City, State, Zip
Email Address *
example@example.com
Driver’s license Number
Telephone
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Your Employer
Occupation
Spouse’s Name
Spouse’s Date of Birth

MonthDayYear
How did you hear about us?
Whom may we Thank for referring you?
Reason for this visit
Emergency Information

Contact person of a relative not living with you.
Name*
Relationship*
Address*
Street Address, City, State, Zip
Home Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Dental Insurance Information
Insured’s Name
Insured’s Social Security Number
Insurance Company
Insured’s ID Number
Insurance Company Address
Street Address, City, State, Zip
Insurance Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Insured’s Employer
Do you have secondary insurance?*

YesNo
If you have dual dental insurance coverage, complete the following section with the secondary insurance carrier information.
Insured’s Name
Insured’s Social Security Number
Insurance Company
Insured’s ID Number
Insurance Company Address
Street Address, City, State, Zip
Insurance Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Insured’s Employer
Medical History
Are you under the care of a physician?

YesNo
If yes, for what condition(s)?
Physician’s Name
Physician’s Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Are you currently taking any medications?*

YesNo
Please List*
Have you ever had the following
Hospitalization for illness or injury*

YesNo
Allergic reaction to*

PenicillinErythromycinCodeineFluorideLatexAspirin, ibuprofen, acetaminophenTetracyclineLocal anestheticMetals (gold, stainless steel, mercury)Any other medicationsNone
List other medications
Heart Problems*

YesNo
Heart Murmur*

YesNo
Rheumatic Fever*

YesNo
Scarlet Fever*

YesNo
High Blood Pressure*

YesNo
Low Blood Pressure*

YesNo
A Stroke*

YesNo
Artificial joint or heart valve*

YesNo
Anemia or other blood disorder*

YesNo
Prolonged bleeding when cut*

YesNo
Emphysema*

YesNo
Tuberculosis*

YesNo
Asthma*

YesNo
Sinus Problems*

YesNo
Kidney Disease*

YesNo
Liver Disease*

YesNo
Jaundice*

YesNo
Thyroid or parathyroid disease*

YesNo
Hormone Deficiency*

YesNo
High Cholesterol*

YesNo
Diabetes*

YesNo
Stomach or duodenal ulcer*

YesNo
Digestive Disorders*

YesNo
Arthritis*

YesNo
Glaucoma*

YesNo
Cosmetic Surgery*

YesNo
Hearing Loss / Hearing Aid*

YesNo
Head or Neck Injuries*

YesNo
Epilepsy, Convulsions (seizures)*

YesNo
Viral infections and/or cold sores*

YesNo
Hives, Skin Rash, Hay Fever*

YesNo
Venereal Disease*

YesNo
Hepatitis*

YesNo
Type?*
HIV / AIDS*

YesNo
Tumor, abnormal growth*

YesNo
Radiation or chemotherapy*

YesNo
Emotional problems/psychiatric treatment*

YesNo
Antidepressant medication*

YesNo
Alcohol / drug dependency*

YesNo
Are you
Often exhausted or fatigued*

YesNo
Subject to frequent headaches*

YesNo
A smoker*

YesNo
How Many?*
Prostate Disorders*

YesNo
Women Only
Taking Birth Control Pills*

YesNo
Pregnant*

YesNo
Due Date*

MonthDayYear
Date
Dental History
Do you have previous dentist*

YesNo
Previous Dentist Name
How Long
Most Recent Dental Exam

MonthDayYear
Date
Most Recent Dental x-rays

MonthDayYear
Date
Most Recent Dental Treatment

MonthDayYear
Date
How often do you have your teeth cleaned?

3mo4mo6mo1yr orMore
What is your immediate dental concern?
Please answer Yes Or No to the following
Unhappy with the appearance of your teeth*

YesNo
Would you like your smile to look better or different?*

YesNo
Teeth sensitive to temperature change*

YesNo
Problems with effectiveness or bad reactions to dental anesthetic?*

YesNo
Orthodontic treatment (braces)*

YesNo
When?*

MonthDayYear
Date
Periodontal (gum) treatment,*

YesNo
When?*

MonthDayYear
Date
Jaw problems (temporomandibular joint/TMJ)*

YesNo
Difficulty opening your mouth widely*

YesNo
Unpleasant taste or odor in your mouth*

YesNo
Burning sensation in your mouth*

YesNo
Bleeding gums*

YesNo
Dental fears*

YesNo
Sore teeth*

YesNo
Difficulty swallowing*

YesNo
Dry mouth, throat, and/or eyes*

YesNo
Stiff neck muscles*

YesNo
Tension headaches*

YesNo
Clench or grind your teeth*

YesNo
Jaw clicking or popping*

YesNo
Lost any teeth*

YesNo
Denture History

( If you are wearing a partial or complete artificial denture, please complete the following )
When did you receive your first partial or complete denture?

MonthDayYear
Date
How long have you worn your present denture?
Has your present denture been relined?*

YesNo
When ?*
Is your present denture a problem?*

YesNo
Describe*
Are you satisfied with the chewing ability?*

YesNo
Consent
*

The undersigned hereby authorizes Doctor to take X-rays, 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 Doctor to perform any and all forms of treatment, medication & therapy, that many be indicated.I also understand the use of anesthetic agents embodies a certain risk.I understand that responsibility for payment for dental services provided in this office for myself or my dependents is mine, due and payable at the time services are rendered.I also assign all insurance benefits to the Doctor.
Signature*
Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

New Patient Registration Form

General Information

Telephone

Emergency Information

Dental Insurance Information

If you have dual dental insurance coverage, complete the following section with the secondary insurance carrier information.

Medical History

Have you ever had the following

Are you

Women Only

Dental History

Please answer Yes Or No to the following

Denture History

Consent