• New Patient Registration

  • We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have questions we'll be glad to help you. We look forward to working with you in maintaining your dental health.

  • Patient Information

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Sex
  • BirthDate
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Primary Insurance

  • BirthDate
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Additional Insurance

  • Is patient covered by additional insurance?
  • Birthdate
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Dental History

  • Reason for Today's Visit
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of last dental care
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of last dental X-rays
     - -
    2 digit month, 2 digit day, 4 digit year
  • Check If you had problem with any of the following

  • Medical History

  • Date of Last Visit
     - -
    2 digit month, 2 digit day, 4 digit year
  • Have you ever taken of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine).
  • Have you had any serious illnesses or operations?
  • Have you ever had a blood transfusion?
  • (Women) Are you pregnant?
  • Nursing?
  • Taking birth control pills?
  • Check if you have or have had any of the following

  • Authorization

  • I certify that I, and/or my dependent(s), have insurance coverage with 

  • and assign directly to Dr

  • all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

  • The above-named dentist may use health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: