www.thirty-twodental.com - New Patients Registration Form.

New Patients Registration Form

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

Title First Name Middle Name Last Name
Prefer to be called
Sex *
Your Date of Birth *

Month Day Year
Age
Home Address *

Street Address

Street Address Line 2

City State

Zip Code, Apt#
Email Address *
example@example.com
Social Security Number
Marital Status
Cell Phone Number *
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Employer
Employer Address

Street Address

Street Address Line 2

City State

Zip Code, Apt#
Occupation
How long there?
College Student? *

Yes No
If Yes, What College?
Collage Name, City, State
Previous Dentist
Present Dentist
Where & when are best times to reach you?
How did you hear about us?
Have you visited our website? *

Yes No
Whom may we Thank for referring you?
Other family members seen by us
Person responsible for account
Spouse Information
His/Her Name
Date of Birth

Month Day Year
Driver’s license Number
Social Security Number
Employer
Cell Phone Number
Please enter a valid phone number.
Relative or friend not living with you
His/Her Name
Cell Phone Number
Please enter a valid phone number.
Relationship
Work Phone Number
Please enter a valid phone number.
Insurance Information
Primary Insurance
Dental coverage? *

Yes No
Insurance Company
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

City State

Zip Code, Apt#
Group Number (Plan, Local or Policy Number)
Insured’s Name
Date of Birth

Month Day Year
Relationship
Social Security Number
Insured’s Employer
Insured’s Employer Address

Street Address

Street Address Line 2

City State

Zip Code Apt#
Do you have Secondary Insurance? *

Yes No
Secondary Insurance
Dental coverage?

Yes No
Insurance Company
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

City State

Zip Code Apt#
Group Number (Plan, Local or Policy Number)
Insured’s Name
Date of Birth

Month Day Year
Relationship
Social Security Number
Insured’s Employer
Insured’s Employer Address

Street Address

Street Address Line 2

City State

Zip Code, Apt#
Medical History
Do you have a personal physician? *

Yes No
Physician’s Name *
Physician’s Phone Number *
Please enter a valid phone number.
Date of last visit

Month Day Year
Date
Your current physical health is *

Good Fair Poor
Please Explain *
Are you currently under the care of a physician? *

Yes No
Please Explain *
Do you smoke or use tobacco in any other form? *

Yes No
Have you had any metal rods, pins or implants? *

Yes No
Are you taking any prescription / Over-the-counter drugs? *

Yes No
Please Explain *
Have you ever taken Fosamax, or any other bisphosphonate? *

Yes No
Do you wear a cardiac pacemaker, or have you had heart surgery? *

Yes No
When? *

Month Day Year
Date
Are you required to take any medication before your dental visit? *

Yes No
What? *
For Women
Are you using a prescribed method of birth control? *

Yes No
Are you Pregnant? *

Yes No
Week Number *
Are you Nursing? *

Yes No
Have you ever had any of the following diseases or medical problems
Congenital Heart Disease *

Yes No
Fainting Spells / Seizures *

Yes No
X-Ray or Cobalt Treatment *

Yes No
Hospitalized for any Reason *

Yes No
Rheumatic / Scarlet Fever *

Yes No
AIDS Related Complex *

Yes No
Anemia *

Yes No
Asthma *

Yes No
Colitis *

Yes No
Diabetes *

Yes No
Emphysema *

Yes No
Excessive Bleeding *

Yes No
Artificial Prosthesis *

Yes No
Glaucoma *

Yes No
Heart Murmur *

Yes No
Herpes / Fever blisters *

Yes No
Allergies or Hives *

Yes No
Liver Disease *

Yes No
Lupus *

Yes No
Cerebral Palsy *

Yes No
Nervous Disorder *

Yes No
Mitral Valve Prolapse *

Yes No
Psychiatric Treatment *

Yes No
Shingles *

Yes No
Stroke *

Yes No
Tuberculosis (TB) *

Yes No
Venereal Disease *

Yes No
Head Injuries *

Yes No
Chicken Pox *

Yes No
Blood Disease *

Yes No
Artificial bones / Joints / Valves *

Yes No
Abnormal Bleeding / Hemophilia *

Yes No
Chemotherapy (Center, Leukemia) *

Yes No
Sickle Cell Disease / Traits *

Yes No
Heart Attack / Surgery *

Yes No
Alcohol / Drug Abuse *

Yes No
Arthritis *

Yes No
Blood Transfusion *

Yes No
Congenital Heart Defect *

Yes No
Difficulty Breathing *

Yes No
Epilepsy / Seizures *

Yes No
Respiratory Disease *

Yes No
Frequent Headaches *

Yes No
Hay Fever *

Yes No
Hepatitis / Jaundice *

Yes No
High Blood Pressure *

Yes No
Kidney Disease *

Yes No
Low Blood Pressure *

Yes No
Angina Pectoris *

Yes No
Joint Replacement *

Yes No
Tumors or Growths *

Yes No
Pacemaker *

Yes No
Radiation Treatment *

Yes No
Sinus Problems *

Yes No
Thyroid Problems *

Yes No
Ulcers *

Yes No
Tonsillitis *

Yes No
Heart Failure *

Yes No
Sinus Trouble *

Yes No
Drug Addiction *

Yes No
Please list any serious medical condition(s) that you have ever had
Are you allergic to any of the following?
Aspirin *

Yes No
Jewelry / Metals *

Yes No
Dental Anesthetics *

Yes No
Erythromycin *

Yes No
Codeine *

Yes No
Latex *

Yes No
Penicillin *

Yes No
Anesthetic (Novocain, ETC) *

Yes No
Sulfa Drugs *

Yes No
Tetracycline *

Yes No
EGGS *

Yes No
Other *

Yes No
Please list any other drugs / Materials that you are allergic to *
Dental History
Why have you come to the dentist today?
Are you currently in pain? *

Yes No
Do you require antibiotics before dental treatment? *

Yes No
Your current dental health is *

Good Fair Poor
Please Explain *
Have you ever had a serious/difficult problem associated with any previous dental work? *

Yes No
Do you Floss Daily? *

Yes No
Brush Daily? *

Yes No
Type of bristles on your toothbrush? *

Hard Medium Soft
Have you ever had gum treatment? *

Yes No
Do your gums ever bleed? *

Yes No
Ever Itch? *

Yes No
Have you ever had periodontal disease? *

Yes No
Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ / TMD)? *

Yes No
Are your teeth sensitive to *

Heat Cold
Anything Else? *
Do you have any loose teeth? *

Yes No
Do you still have wisdom teeth? *

Yes No
Would you like fresher breath? *

Yes No
Whiter Teeth? *

Yes No
Are you happy with the way your smile looks? *

Yes No
If Not, What Would You Change? *
*

The information and health history, and preceding answers are true and correct to the best of my knowledge. I authorize and give consent to perform dental services agreed between doctor and patient and/or guardian to be necessary or advisable, including the use of local anesthesia and other medications as indicated. I agree that, regardless of insurance coverage, I am responsible for payment for services rendered. If I ever have any changes in my health or if my medication change, I will, without fail, inform the doctor at my next appointment.
Signature *

Clear
Name *

First Name Last Name
Date *

Month Day Year
Date
Should be Empty:

New Patients Registration Form

About you

Spouse Information

Relative or friend not living with you

Insurance Information

Secondary Insurance

Medical History

For Women

Have you ever had any of the following diseases or medical problems

Are you allergic to any of the following?

Dental History