Patient Registration Form
Burlington Location
Are you a new or existing patient?
*
New Patient
Existing Patient
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birth Date:
*
-
Month
-
Day
Year
Date
Sex:
Male
Female
Email:
*
Enter your best email
Martial Status
*
Please Select
Single
Married
How did you hear about us?
*
Please Select
Friends/Family
Social Media
Ads
Do you use tobacco in any form?
*
Yes
No
When did you last have dental x-rays?
*
-
Month
-
Day
Year
Date
How often do you floss?
How often do you brush your teeth?
*
Emergency Contact
Name of your Emergency Contact:
*
First Name
Last Name
Emergency Contact Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship:
*
Medical Conditions
Please select all that applies:
Allergies; Indicate which of the following you have had, or have at present.
Local Anesthetics
Latex Sensitivity
Penicillin
Aspirin or Codeine
Sulfa Drugs
Other
Respiratory; Indicate which of the following you have had, or have at present.
Asthma/ Hay Fever
Sinus Problems
Difficulty breathing while laying down
COPD/Lung Disease
Heart/Blood Vessels; Indicate which of the following you have had, or have at present.
Rheumatic Fever
Heart Murmur
Chest Pain/Discomfort
Heart Attack/Stroke
High Blood Pressure
Shortness of Breath
Mitral Valve Prolapse
Dental Condition; Indicate which of the following you have had, or have at present.
Bleeding, Soft Gums
Unpleasant Taste/Bad Breathe
Blisters/Lumps in Mouth
Ortho Treatment (Braces)
Clicking/Popping Jaw
Experience any accidents/Blow to your jaw
Teeth Sensitivity (hot & cold)
Facial Pain
Difficulty Chewing/Swallowing
Food pack or catch between your teeth
Clenching or Grinding
Shifting in Teeth
Yellow Teeth
Blood; Indicate which of the following you have had, or have at present.
Bruise Easily
Anemia
Blood Transfusion
Bleeding Disorder
Excessive Bleeding/Long Healing
Digestive System; Indicate which of the following you have had, or have at present.
Hepatitis
Liver Disease/Jaundice
Ulcers
Kidney Trouble
Immune System; Indicate which of the following you have had, or have at present.
Radiation/Chemotherapy
AIDS/HIV
Cancer
Nervous System; Indicate which of the following you have had, or have at present.
Headaches
Convulsions/Epilepsy
Dizziness/Fainting
Psychiatric Treatment
Trigeminal Neuralgia
Endocrine; Indicate which of the following you have had, or have at present.
Diabetes
Hypoglycemia
Thyroid Condition/ Goiter
Bone/Muscles; Indicate which of the following you have had, or have at present.
Arthritis/Rheumatism
Artificial Joints/Limbs
Osteoporosis
Neck Aches
Are you being treated for any medical condition at the present time or have you been treated within the past year?
*
Yes
No
If yes, which medical condition at the present time or have you been treated within the past year?
Are you taking any medications, non-prescription drugs or herbal supplements of any kind?
*
Yes
No
If yes, please list any medication, non-prescription drugs or herbal supplements of any kind.
Are there any diseases or medical problems that run in your family?
*
Yes
No
If yes, please list any diseases or medical problems that run in your family.
Eg. Diabetes, Cancer, Heart Disease, etc.
Women: Are you pregnant or breastfeeding?
Yes
No
Dental Benefits Information/Policy Holder
Name of Insurance Policy Holder:
First Name
Last Name
Birth Date:
-
Month
-
Day
Year
Date
Insurance Company Name:
Policy Number:
Policy Contact Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Enter the Certificate/Subscriber ID:
Signature:
Continue
Continue
Should be Empty: