www.smilesraleigh.com - Patient Registration Form

  • Patient Registration Form

    Please note that it is important to fill in the fields before submitting. Thank you.

  • Print blank form to fill by hand

  • Office Location*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Have you visited our website?*

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  • Method of payment

  • Note : Care Credit are not accepted.

  • DENTAL INSURANCE COVERAGE

  • Format: (000) 000-0000.
  • Date*
     - -

  • Dental History

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

  • Print blank form to fill by hand

  • Select the appropriate answer. If you don't know the correct answer, please select “Don't know”.

  • Have you made regular dental visits?*
  • Were dental x-rays taken?*
  • Have you lost any teeth or have any teeth been removed?*
  • Have they been replaced?*
  • How have they been replaced?*
  • .Are you happy with the replacement?*
  • Would you like to know about permanent replacements?*
  • Have you ever had any problems or complications with previous dental treatment?*
  • Do you clench or grind your teeth?*
  • Does your jaw pop or click?*
  • Have you experienced any pain or soreness in the muscles in your face or around your ear?*
  • Do you have frequent headaches, neckaches or shoulder aches?*
  • Does food get caught in your teeth?*
  • Are any of your teeth sensitive to*
  • Do your gums bleed or hurt?*
  • Have you ever had gum treatment or surgery?*
  • Do you feel your breath is offensive at times?*
  • How often do you brush your teeth daily?
  • Do you use dental floss?*
  • Are any of your teeth
  • Are you happy with the appearance of your teeth?*
  • Have you had orthodontic work?*
  • Do you have any questions or concerns?*
  • Date
     - -

  • Medical History

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

  • Print blank form to fill by hand

  • Select the appropriate answer. If you don't know the answer please select 'Don't know'.

  • Are you under a physician’s care?*
  • When was your last complete physical exam?
     - -
  • Are you taking any medication or substances?*
  • Do you routinely take health related substances?(vitamin, herbal supplements, natural products)?*
  • Are you allergic to any medications or substances?*
  • Do you have any other allergies or hives?*
  • Do you have any problems with penicillin, antibiotics, anesthetics or other medications?*
  • Are you sensitive to any metals or latex?*
  • Are you pregnant or suspect you may be?*
  • Do you use any birth control medications?*
  • Have you ever been treated for or been told you might have heart disease?*
  • Do you have a pacemaker, an artificial heart valve, implant or been diagnosed with mitral valve prolapse?*
  • Have you ever had rheumatic fever resulting in rheumatic heart disease?*
  • Are you aware of any heart murmurs?*
  • Do you have blood pressure problems?*
  • Have you ever had a serious illness or major surgery?*
  • Have you ever had radiation treatment or chemotherapy for a tumor, growth or other condition?*
  • Do you have inflammatory diseases, such as arthritis or rheumatism?*
  • Do you have any artificial joints or prostheses?*
  • Do you have any blood disorders such as anemia, leukemia, etc.?*
  • Have you ever bled excessively after being cut or injured?*
  • Do you have any stomach problems?*
  • Do you have any kidney problems?*
  • Do you have any liver problems?*
  • Are you diabetic?*
  • Do you have fainting or dizzy spells?*
  • Do you have asthma?*
  • Do you have epilepsy or seizure disorders?*
  • Do you or have you ever had a venereal disease?*
  • Have you tested positive for HIV?*
  • Do you have AIDS?*
  • Have you had or do you test positive for Hepatitis?*
  • Do you or have you had Tuburculosis (TB)?*
  • Do you smoke, chew, use snuff or any other forms of tobacco?*
  • Do you regularly consume more than one or two alcoholic beverages a day?*
  • Have you had psychiatric treatment?*
  • Do you habitually use controlled substances, legal or illegal?*
  • Have you taken any of the following? Fenfluramine, fenfluramine combined with phentermine (fen-phen), Dexfenfluramine (redux), or other weight loss products?*
  • Do you have any disease condition, or problem not listed?*
  • Would you like to speak to the Doctor privately about any problem?*
  • Date*
     - -

  • Mercury Toxicity

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

  • Print blank form to fill by hand

  • Do you have mercury / silver fillings?*
  • Have any of your mercury / silver fillings been replaced?*
  • Were your fillings removed using a rubber dam?*
  • Did you have mercury / silver fillings in your baby teeth?*
  • Did you have all of your childhood vaccines?*
  • Do you currently take the flu vaccine?*
  • Were you on or near farms?*
  • Were you near large industry?*
  • Have you ever siphoned gasoline with your mouth or washed your hands in gasoline?*
  • Did you ever play or work in apple, peach, citrus or other orchards?*
  • Where you ever diagnosed with mercury or heavy metal toxicity?*
  • Are there lab reports?*
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  • Have you been doing any detoxification?*
  • Do you have a diagnosed disease or disability thought to be related?*
  • Are you still seeing that provider?*
  • Are they supportive of alternative care?*
  • Do they know you are here?*
  • Date*
     - -
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