New Patient Registration
Please provide us with the following personal and medical information so that we can give you the highest standard of dental care. All information collected is strictly confidential.
This patient is an:
*
Please Select
Adult
Child
Adult under guardianship
Prefix:
Please Select
Mr.
Mrs.
Ms.
Dr.
Name
*
First Name
Last Name
Nickname
Date of Birth
*
/
Month
/
Day
Year
Date
Sex
*
Male
Female
Mobile Phone Number
*
Format: (000) 000-0000.
Home Phone Number
Format: (000) 000-0000.
Work Phone Number
Format: (000) 000-0000.
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
Primary Dental Insurance Information
Insurance Co. Name
Certificate #
Group #
Employer
Subscriber Name
First Name
Last Name
Date of Birth
/
Month
/
Day
Year
Date
Sex
Male
Female
Relationship to Patient
Self
Spouse
Child
Other
Secondary Dental Insurance Information
Insurance Co. Name
Certificate #
Group #
Employer
Subscriber Name
First Name
Last Name
Date of Birth
/
Month
/
Day
Year
Date
Sex
Male
Female
Relationship to Patient
Self
Spouse
Child
Other
Who may we thank for referring you?
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Medical History
What is your family physicians' name?
*
Family Physician's Phone Number:
-
Area Code
Phone Number
Have you ever been hospitalized or had a major surgery?
*
Yes
No
If yes, please specify:
Are you currently being treated for any medical condition?
*
Yes
No
If yes, please specify:
Have you ever had a serious head or neck injury?
*
Yes
No
If yes, please specify:
Have you ever had abnormal bleeding?
*
Yes
No
If yes, please specify:
Are you currently taking any medications or drugs (including herbal supplements)?
*
Yes
No
If yes, please list all:
Do you use tobacco?
*
Yes
No
Do you have any allergies (including medications)?
*
Yes
No
If yes, please specify:
Do you have, or have you had, any of the following?
*
AIDS/HIV Pod
Alzheimer's Disease
Anaphylaxis
Asthma
Blood Disease
Blood Transfusion
Cancer
Chemotherapy
Congenital Heart Disorder
Diabetes
Epilepsy
Fainting Spells
Frequent Cough
Heart Attack
Hep A
Hep B
Hep C
Herpes
High Blood Pressure
Kidney Problems
Liver Disease
Low Blood Pressure
Lung Disease
Radiation
Stroke
Tuberculosis
Ulcers
None of the above
Other
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Dental History
When was your last dental visit?
*
-
Month
-
Day
Year
Date Picker Icon
When was your last dental cleaning?
*
-
Month
-
Day
Year
Date Picker Icon
How often do you brush your teeth?
*
How often do you use dental floss?
*
Have you ever had local anesthetic (freezing)?
*
Yes
No
If yes, were there any complications?
Dental Condition (please indicate which, if any, of the following you presently have):
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Bleeding or swollen gums
Loose teeth
Lumps or sores in mouth
Sensitivity to hot/cold or sweets
Unpleasant taste/bad breath
Orthodontic treatment (ie. braces, retainers)
Clicking/popping jaw
Facial pain
Broken or chipped teeth
Clenching/grinding
Oral habits (ie. thumb-sucking, nail-biting, etc.)
None of the above
Are you satisfied with the appearance of your teeth/smile?
*
Yes
No
If no, what would you like to see changed?
General Release
I agree that the medical and dental information provided is accurate and have not knowingly omitted any information. Should there be any change in either my health status or other information I have provided, I will advise this dental office. I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that information provided from or to my medical doctor or other health provider may be necessary. I have been advised of the privacy policy of the office and that my personal information will be collected, used and disclosed within the guidelines of this policy. I understand that responsibility for payment of dental services is mine, and I assume responsibility for fees associated with these services.
Signature of Patient or Guardian:
*
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