• Welcome to Our Practice

  • Patient Registration and Health History

  • DATE
     - -
  • GENDER
  • DOB
     - -
  • Format: (000) 000-0000.

  • Dependent Information and Marketing Information

  • GENDER
  • HOW DID YOU HEAR ABOUT US?

  • DENTAL INSURANCE INFORMATION

  • SUBSCRIBER BIRTH DATE
     - -

  • SECONDARY INSURANCE INFORMATION

  • SUBSCRIBER BIRTH DATE
     - -

  • Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication you may be taking, could have an important relationship with the dentistry you will receive. Thank you for answering the following questions.

  • MEDICAL HISTORY

  • Are you under a physician’s care now?
  • Have you ever been hospitalized or had a major operation?
  • Have you ever had a serious head or neck injury?
  • Are you taking any medications, pills, or drugs?
  • Do you take, or have you taken Phen-fen or Redux?
  • Are you on a special diet?
  • Do you use tobacco?
  • Do you use controlled substances?

  • Women

  • Are you Pregnant or trying to get pregnant?
  • Nursing?
  • Taking oral contraceptives?

  • ARE YOU ALLERGIC TO ANY OF THE FOLLOWING?

  • Aspirin
  • Acrylic
  • Codeine
  • Latex
  • Local Anesthetics
  • Metal
  • Penicillin
  • Do you have any of the following? (Check all that apply)
  • Have you ever had any serious illness not listed above?
  • Should be Empty: