Brentwooddentalcare.net - New Patient Registration

New Patient Registration
Patient Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Age
Gender *
Social Security Number
Driver’s License Number
Marital Status
Address

Street Address

Street Address Line 2

CityState / Province

Zip Code / Apt #
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Ext
Email Address*
example@example.com
Employer
Occupation
How did you hear about our office
Whom may we thank for referring you?
Are You a full time student?*

YesNo
If Patient is Minor
Mother's Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Father's Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Person Responsible For Account
His / Her Name
Spouse's Details or If Minor Parent's Details
His / Her Name
Employer
Social Security Number
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Ext
Emergency Contact Information
His / Her Name*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Zip Code / Apt #
Any other Family in the Household

(Kids, Husband, Wife, etc.)
Click (+) for add more
Dental Insurance Information
Primary Carrier
Insured’s Name
Date of Birth

MonthDayYear
Social Security Number
Insured’s Employer
Insurance Co
Address

Street Address

Street Address Line 2

CityState / Province

Zip Code / Apt #
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Group Number
Policy Number
Do you have secondary insurance?*

YesNo
If You Have A Dual Insurance Coverage, Complete This For The Second Coverage.

(This Office Bills Primary Ins Only)
Insured’s Name
Date of Birth

MonthDayYear
Social Security Number
Insured’s Employer
Insurance Co
Address

Street Address

Street Address Line 2

CityState / Province

Zip Code / Apt #
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Group Number
Local Number
Dental History
Please Check Any Of The Following That Apply To You
Sensitivity (Hot, Cold, Sweet)Headaches, Ear aches, Neck or jaw joint pain.Mouth ulcers or cold soresTeeth or filling breakingGrinding or clenching teethBleeding, swollen or irritated gumsLoose, tipped or shifting teethBad breath
If Select "Sensitivity (Hot, Cold, Sweet)" Where?

URLRULLL
Do you smoke or use chewing tobacco?*

YesNo
How Much?*
For how long?*
If I could make my teeth healthier, I would
Make my teeth whiterClose spacesRepair chipped teethReplace old crowns that don't matchReplace metal fillings with tooth colored restorationsMake my teeth straighterHave a smile makeoverReplace missing teeth
Do You Have Or Have You Had Any Of The Following?
CrownsBracesMissing TeethGum Treatments
On A Scale Of 1 - 10, With 10 Being The Highest Rating
How important is your dental health to you?

1

2

3

4

5

6

7

8

9

10

1 is Worst, 10 is Best
Where would you rate your current dental health?

1

2

3

4

5

6

7

8

9

10

1 is Worst, 10 is Best
Where would you like your dental health to be?

1

2

3

4

5

6

7

8

9

10

1 is Worst, 10 is Best
Please Share Following Dates
Your Last Cleaning

MonthDayYear
Date
Your Last Oral Cancer Screening

MonthDayYear
Date
Last Complete X-rays

MonthDayYear
Date
Why did you leave your previous dentist?
Previous dentist's
Dentist Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Dentist Address

Street Address

Street Address Line 2

CityState / Province

Zip Code / Apt #
What is the most important thing to you about your future smile and dental health?
What is the most important thing to you about your dental visit today?
Medical History
Have you had any of the following
Allergies (Seasonal)*

YesNo
Artificial Heart Valve*

YesNo
Asthma*

YesNo
If you have Asthma, have you ever had to go to a hospital or emergency room for treatment?*

YesNo
Anemia*

YesNo
Artificial Joints*

YesNo
Blood Disease*

YesNo
Cancer*

YesNo
Diabetes*

YesNo
Drug Addiction*

YesNo
Excessive Bleeding*

YesNo
Heart Conditions*

YesNo
Hepatitis A*

YesNo
Hepatitis C*

YesNo
High Blood Pressure*

YesNo
Jaundice*

YesNo
Liver Disease*

YesNo
Nervousness / Depression*

YesNo
Phen Fen (1 month +)*

YesNo
Respiratory Problems*

YesNo
Rheumatism*

YesNo
Seizures*

YesNo
Stroke*

YesNo
Tuberculosis*

YesNo
Snoring*

YesNo
Fatigue*

YesNo
Bruise Easily*

YesNo
Chemotherapy*

YesNo
Dizziness / Fainting*

YesNo
Emphysema*

YesNo
Glaucoma*

YesNo
Heart Murmur*

YesNo
Hepatitis B*

YesNo
Chronic Pain*

YesNo
HIV / AIDS*

YesNo
Kidney Disease*

YesNo
Mitral Valve Prolapse*

YesNo
Pacemaker*

YesNo
Radiation (Head / Neck)*

YesNo
Rheumatic Fever*

YesNo
Scarlet Fever*

YesNo
Stomach Problems*

YesNo
Thyroid Disease*

YesNo
Ulcers*

YesNo
Sleep Apnea*

YesNo
Migraines*

YesNo
Other*

YesNo
If "Other" Please List*
Do You Have An Allergy To Any Of The Following?
AspirinLatexNitrous OxideCodeineErythromycinLocal AnestheticPenicillinOther
If "Other" Please List*
Have you taken any medication for Osteoporosis or any bone density condition?*

YesNo
What Medications Are You Currently Taking?*
For Women Only
Birth Control PillsBreast-FeedingPregnant
1-3 months3-6 months6-9 months
Are you under a physician's care*

YesNo
For What?*
Family Physician
When was your last physical

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Is there any other medical or dental information we should know about?
Signature*
Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

New Patient Registration

If Patient is Minor

Person Responsible For Account

Spouse's Details or If Minor Parent's Details

Emergency Contact Information

Any other Family in the Household

Dental Insurance Information

Primary Carrier

If You Have A Dual Insurance Coverage, Complete This For The Second Coverage.

Dental History

Please Check Any Of The Following That Apply To You

If I could make my teeth healthier, I would

Do You Have Or Have You Had Any Of The Following?

On A Scale Of 1 - 10, With 10 Being The Highest Rating

Please Share Following Dates

Medical History

Have you had any of the following

Do You Have An Allergy To Any Of The Following?

For Women Only