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 Name
Middle Name
Last Name
Your Birthday
*
Please select a month
January
February
March
April
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June
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December
Month
Please select a day
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Day
Please select a year
2025
2024
2023
2022
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2020
2019
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1927
1926
1925
1924
1923
1922
1921
1920
Year
Age
Gender
*
Please Select
Male
Female
Social Security Number
Marital Status
Please Select
Single
Married
Separated
Divorced
Widowed
Full Time Student?
Yes
No
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.
Work Phone Number
Please enter a valid phone number.
Cell Phone Number
*
Please enter a valid phone number.
Your Employer
Occupation
Spouse’s Name
Spouse’s Date of Birth
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
How did you hear about us?
Please Select
Internet
Search Engine
Facebook
Twitter
Yellow Pages
Newspaper
Referral
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.
Cell Phone Number
*
Please enter a valid phone number.
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.
Insured’s Employer
Do you have secondary insurance?
*
Yes
No
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.
Insured’s Employer
Medical History
Are you under the care of a physician?
Yes
No
If yes, for what condition(s)?
Physician’s Name
Physician’s Phone Number
Please enter a valid phone number.
Are you currently taking any medications?
*
Yes
No
Please List
*
Have you ever had the following
Hospitalization for illness or injury
*
Yes
No
Allergic reaction to
*
Penicillin
Erythromycin
Codeine
Fluoride
Latex
Aspirin, ibuprofen, acetaminophen
Tetracycline
Local anesthetic
Metals (gold, stainless steel, mercury)
Any other medications
None
List other medications
Heart Problems
*
Yes
No
Heart Murmur
*
Yes
No
Rheumatic Fever
*
Yes
No
Scarlet Fever
*
Yes
No
High Blood Pressure
*
Yes
No
Low Blood Pressure
*
Yes
No
A Stroke
*
Yes
No
Artificial joint or heart valve
*
Yes
No
Anemia or other blood disorder
*
Yes
No
Prolonged bleeding when cut
*
Yes
No
Emphysema
*
Yes
No
Tuberculosis
*
Yes
No
Asthma
*
Yes
No
Sinus Problems
*
Yes
No
Kidney Disease
*
Yes
No
Liver Disease
*
Yes
No
Jaundice
*
Yes
No
Thyroid or parathyroid disease
*
Yes
No
Hormone Deficiency
*
Yes
No
High Cholesterol
*
Yes
No
Diabetes
*
Yes
No
Stomach or duodenal ulcer
*
Yes
No
Digestive Disorders
*
Yes
No
Arthritis
*
Yes
No
Glaucoma
*
Yes
No
Cosmetic Surgery
*
Yes
No
Hearing Loss / Hearing Aid
*
Yes
No
Head or Neck Injuries
*
Yes
No
Epilepsy, Convulsions (seizures)
*
Yes
No
Viral infections and/or cold sores
*
Yes
No
Hives, Skin Rash, Hay Fever
*
Yes
No
Venereal Disease
*
Yes
No
Hepatitis
*
Yes
No
Type?
*
HIV / AIDS
*
Yes
No
Tumor, abnormal growth
*
Yes
No
Radiation or chemotherapy
*
Yes
No
Emotional problems/psychiatric treatment
*
Yes
No
Antidepressant medication
*
Yes
No
Alcohol / drug dependency
*
Yes
No
Are you
Often exhausted or fatigued
*
Yes
No
Subject to frequent headaches
*
Yes
No
A smoker
*
Yes
No
How Many?
*
Prostate Disorders
*
Yes
No
Women Only
Taking Birth Control Pills
*
Yes
No
Pregnant
*
Yes
No
Due Date
*
-
Month
-
Day
Year
Date
Dental History
Do you have previous dentist
*
Yes
No
Previous Dentist Name
How Long
Most Recent Dental Exam
-
Month
-
Day
Year
Date
Most Recent Dental x-rays
-
Month
-
Day
Year
Date
Most Recent Dental Treatment
-
Month
-
Day
Year
Date
How often do you have your teeth cleaned?
3mo
4mo
6mo
1yr or
More
What is your immediate dental concern?
Please answer Yes Or No to the following
Unhappy with the appearance of your teeth
*
Yes
No
Would you like your smile to look better or different?
*
Yes
No
Teeth sensitive to temperature change
*
Yes
No
Problems with effectiveness or bad reactions to dental anesthetic?
*
Yes
No
Orthodontic treatment (braces)
*
Yes
No
When?
*
-
Month
-
Day
Year
Date
Periodontal (gum) treatment,
*
Yes
No
When?
*
-
Month
-
Day
Year
Date
Jaw problems (temporomandibular joint/TMJ)
*
Yes
No
Difficulty opening your mouth widely
*
Yes
No
Unpleasant taste or odor in your mouth
*
Yes
No
Burning sensation in your mouth
*
Yes
No
Bleeding gums
*
Yes
No
Dental fears
*
Yes
No
Sore teeth
*
Yes
No
Difficulty swallowing
*
Yes
No
Dry mouth, throat, and/or eyes
*
Yes
No
Stiff neck muscles
*
Yes
No
Tension headaches
*
Yes
No
Clench or grind your teeth
*
Yes
No
Jaw clicking or popping
*
Yes
No
Lost any teeth
*
Yes
No
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?
-
Month
-
Day
Year
Date
How long have you worn your present denture?
Has your present denture been relined?
*
Yes
No
When ?
*
Is your present denture a problem?
*
Yes
No
Describe
*
Are you satisfied with the chewing ability?
*
Yes
No
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 Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: