• Patient Registration Form

  • Today’s Date:*
     - -
  • Format: (000) 000-0000.
  • ​Preferred Contact
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Insurance Information

    (Please give your insurance card to the receptionist)
  • Do you have Secondary Dental Insurance?*

  • In Case of Emergency

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

  • I authorize the specialist to conduct a dental examination and perform treatment as deemed necessary for proper dental care

    I understand that additional diagnostic procedures and dental treatments may be recommended and will be discussed with me prior to being done.

    I understand that I am responsible for payments in full for all professional services at the time each service is performed. I understand that an estimate of treatment costs will be given to all new and recall patients and that actual cost for services may be higher or lower. By signing this form, I revoke all previous agreements to the contrary and agree to be responsible for payment of service not paid in whole or in part by my dental care provider.

    I authorize the communication and release of information concerning my (my child’s) related treatment to other dentists or specialists.

    I authorize the communication and release of information contained in my claim forms to my insurance provider/plan administrator.

    I understand that prior to any scheduled surgical procedure, the office may contact me in advance to review and update my medical history, confirm my pharmacy information, and review or obtain necessary consent forms. I acknowledge that accurate and current medical and pharmacy information is required to ensure safe treatment. I further understand that prescriptions related to my procedure may be prepared and forwarded to my pharmacy prior to the date of surgery when clinically appropriate.

    APPOINTMENT POLICY: Our policy requires that if you wish to cancel an appointment, you must provide our office with 2 business days’ notice. Please note that we are unable to accept cancellations via email or after hours. Appointment cancellations with less than 2 business days’ notice may incur a $50 fee.

    SURGICAL APPOINTMENT DEPOSIT POLICY: Surgical procedures require advance preparation and dedicated clinical time. A non-refundable deposit of $300 is required two (2) weeks prior to the scheduled surgery date in order to secure the appointment. This deposit will be applied toward the total cost of the procedure. If a surgical appointment is cancelled or rescheduled with less than two (2) weeks’ notice, the $300 deposit will be forfeited. Failure to provide the required deposit by the specified deadline may result in cancellation of the surgical appointment.

    I have read the above conditions and agree with their content.

  • Date*
     - -

  • Dental History

    Please Check “Yes” or “No” to indicate if you have had any of the following
  • Bad Breath*
  • Bleeding gums*
  • Gums swollen or tender*
  • Loose teeth*
  • Food collection between teeth*
  • Sensitivity to hot or cold*
  • Sensitivity to sweets*
  • Sensitivity when biting*
  • Previous periodontal treatment*
  • Sores or growths in your mouth*
  • Blisters on lips or mouth*
  • Burning sensation on tongue*
  • Grinding teeth/bruxism*
  • Jaw pain or tiredness*
  • Fingernail biting*
  • Chew ice cubes regularly*
  • Clicking or popping jaw*
  • Orthodontic treatment*
  • Dry mouth*
  • Mouth breathing*
  • Lip or cheek biting*
  • Have you had your teeth bleached?*
  • Are you a smoker?*
  • Have you had any serious trouble associated with any previous dental treatment?*
  • Do you bleed excessively after tooth extraction?*
  • Do you have a bad taste in your mouth?*
  • Have you had any undesirable reactions to local or general anesthetics?*
  • Are you happy with the appearance of your teeth?*
  • Have you had excessive pain or swelling after oral surgery?*
  • Are you willing to become actively involved in the treatment of your periodontal disease?*

  • IMAGE RELEASE CONSENT

  • I {patientsName}, GRANT CLEARCARE PERIODONTAL & IMPLANT CENTRE PERMISSION TO TAKE PHOTOGRAPHS AND/OR VIDEOS OF MY JAW AND TEETH (FULL-FACE SHOTS WILL NOT BE USED) FOR MAINTAINING RECORDS FOR RESEARCH, EDUCATION (LECTURES AND SEMINARS) AND MARKETING MATERIAL (WEBSITES, SOCIAL MEDIA, PRINTED MATERIALS, PATIENT EDUCATION). I UNDERSTAND MY NAME WILL BE KEPT CONFIDENTIAL. IF MY PHOTOGRAPHS AND/OR VIDEOS ARE USED THEY WILL NOT CONTAIN ANY IDENTIFIABLE INFORMATION.

    IMAGES WILL BE STORED IN A SECURED LOCATION AND ONLY AUTHORIZED STAFF WILL HAVE ACCESS TO THEM. THEY WILL BE KEPT AS LONG AS THEY ARE RELEVANT AND AFTER THAT TIME DESTROYED OR ARCHIVED.

  • Date*
     - -

  • Medical History

    Please Check “Yes” or “No” to indicate if you have had any of the following
  • Are you currently taking any medications?*
  • Do you require premedication before dental treatment?*
  • Are you sensitive or allergic to any medication?*
  • HIV/AIDS*
  • Cancer/Chemotherapy *
  • Asthma*
  • Tuberculosis*
  • Rheumatic Fever*
  • Scarlett Fever*
  • Heart Murmur*
  • Thyroid Disease*
  • Hepatitis*
  • Diabetes*
  • Epilepsy or Seizures*
  • Pacemaker*
  • Psychiatric treatment*
  • High Blood Pressure*
  • Low Blood Pressure*
  • Stroke*
  • Anemia*
  • Ulcers*
  • Arthritis*
  • Cold Sores (Herpes)*
  • Kidney Disease*
  • Bladder Disease*
  • Nervousness*
  • Fainting or Dizzy Spells*
  • Do you have pain in the chest upon exertion?*
  • Do you have shortness of breath?*
  • Do you bruise easily?*
  • Have you ever had Yellow Jaundice?*
  • Are you thirsty much of the time?*
  • Have you lost or gained weight (more than 10 pounds) in the last year?*
  • Are you following a diet?*
  • Has a doctor ever said you have cancer or a tumor?*
  • Have you ever had excessive bleeding from a cut or wound?*
  • Do you have frequent severe headaches?*
  • Do you sometimes take medicine to relieve nervousness?*
  • Are you taking birth control pills?*
  • Are you pregnant?*
  • Do you have any disease, condition, or problem not listed above?*

  • TO THE BEST OF MY KNOWLEDGE ALL OF THE ABOVE ANSWERS ARE TRUE AND CORRECT. IF I HAVE ANY CHANGE IN MY CONTACT INFORMATION, CHANGE OF ADDRESS, CHANGE OF INSURANCE OR CHANGE IN HEALTH, I WILL INFORM AT MY NEXT APPOINTMENT. 

  • Date*
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  • Should be Empty: