www.azusafamilydentistry.com - New Dental Patient Registration Form

New Dental Patient Registration Form
Patient Information
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Occupation
Employer
Preferred Contact Method
Emergency Contact
Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Information
Insurance Company
Member ID
Group Number
Policy Holder Name
Policy Holder Date of Birth

MonthDayYear
Dental History
Reason for Today's Visit:
Date of Last Dental Visit

MonthDayYear
Date
Date of Last Dental Cleaning

MonthDayYear
Date
Have you ever had any of the following?
Do you currently have
If "Other" Please Explain
Medical History
Are you currently under a physician's care?
Physician Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Are you taking any medications?
If yes, please list
Do you have any allergies?
If "Other" Please Explain
Do you have or have you had
If "Other" Please Explain
Consent & Acknowledgment
I certify that the information provided is accurate and complete to the best of my knowledge. I understand that providing incorrect information may affect my dental treatment.

I authorize the dental office to perform necessary examinations, diagnostic procedures, and treatment as discussed.
Patient/Guardian Signature
Name

First NameLast Name
Date

MonthDayYear
Date
Should be Empty:

New Dental Patient Registration Form