glendorafamilydental.com - Dental Registration Form

DENTAL REGISTRATION AND HISTORY
PATIENT INFORMATION
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
SS/HIC/Patient ID #
Patient Name

Last NameFirst NameMiddle Initial
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Sex
Age
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Marital Status
Partnered for how many years?
Patient Employer/School
Occupation
Employer/School Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer/School Phone
Please enter a valid phone number.Format: (000) 000-0000.
Spouse's Name
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
SS#
Spouse's Employer
Whom may we thank for referring you?
DENTAL INSURANCE
Who is responsible for this account?
Relationship to Patient
Insurance Co.
Group #
Is patient covered by additional insurance?
Subscriber's Name
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
SS#
Relationship to Patient
Insurance Co.
Group #
ASSIGNMENT AND RELEASE
I certify that I, and/or my dependent(s), have insurance coverage with Name of Insurance Company(ies)and assign directly to the doctor all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named dentist may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.
Signature of Patient, Parent, Guardian or Personal Representative
Please print name of Patient, Parent, Guardian or Personal Representative
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Relationship to Patient
PHONE NUMBERS
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work
Please enter a valid phone number.Format: (000) 000-0000.
Ext
Cell
Please enter a valid phone number.Format: (000) 000-0000.
Spouse's Work
Please enter a valid phone number.Format: (000) 000-0000.
Best time and place to reach you
IN CASE OF EMERGENCY, CONTACT

(Specify someone who does not live in your household.)
Name
Relationship
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
DENTAL HISTORY
Reason for today’s visit
Former Dentist
City/State
Date of last dental visit

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of last dental X-rays

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Place a mark on “yes” or “no” to indicate if you have had any of the following:

Rows	Yes	No
Bad breath
Bleeding gums
Blisters on lips or mouth
Burning sensation on tongue
Chew on one side of mouth
Cigarette, pipe, or cigar smoking
Clicking or popping jaw
Dry mouth
Fingernail biting
Food collection between the teeth
Foreign objects
Grinding teeth
Gums swollen or tender
Jaw pain or tiredness
Lip or cheek biting
Loose teeth or broken fillings
Mouth breathing
Mouth pain, brushing
Orthodontic treatment
Pain around ear
Periodontal treatment
Sensitivity to cold
Sensitivity to heat
Sensitivity to sweets
Sensitivity when biting
Sores or growths in your mouth

How often do you floss?
How often do you brush?
Should be Empty:

DENTAL REGISTRATION AND HISTORY

PATIENT INFORMATION

DENTAL INSURANCE

ASSIGNMENT AND RELEASE

PHONE NUMBERS

IN CASE OF EMERGENCY, CONTACT

DENTAL HISTORY