New Patient Registration

New Patient Registration
Patient's Legal Name*

First NameLast Name
Patient's Preferred Name
Gender
Date of Birth (MM.DD.YYYY)*

MonthDayYear
Date
Person Responsible for Account (if under 18)
How did you hear about us?*

NewspaperGoogleWalking ByWebsiteFacebookOther
If you heard about us from an existing patient - we'd love to thank them! Please let us know who to thank here:
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Preferred Contact Number

HomeWorkCell
Email
example@example.com
Personal Healthcare Number
Status Number (if applicable)
By signing below I acknowledge that regardless of any insurance status, I am responsible for the balance due on this account for any and all professional services rendered. I understand payment is expected at the time of treatment unless prior arrangements have been made with the office.

I understand that when an appointment is booked, it is considered reserved and if I do not provide at least one business days notice to reschedule, I will be responsible for a missed appointment fee between $50-200 depending on the length of my appointment. Repeated no-shows will result in me having to make a deposit in order to book an appointment.
Signature*
Health History
Last Dental Check-Up
Previous Dentist
Select all which apply to you

There is something about the appearance of my teeth I would like to changeI sometimes feel self-conscious/uncomfortable about the appearance of my teethI am aware of current dental problemsI have had an unfavorable dental experienceI have trouble with dental anestheticI have had orthodontic treatmentI have been treated for periodontal (gum) diseaseI notice an unpleasant odor/smell in my mouthI have had cavities in the past 3 yearsMy teeth are sensitive to hot/cold/biting/sweetsI frequently get food caught between my teethI have problems with my jaw joint (pain, sounds, clicking, locking, clenching)My teeth are crowding or developing spacesI have trouble with sleep/wake up with awareness to my teethI have worn/do wear a bite applianceI have had an injury involving my face/jawI have had swelling or lumps in my mouth

Do you have:*

	Yes	No
Do you have an artificial heart valve?
Do you have a pacemaker or implantable defibrillator?
Have you ever had a stroke?
Do you have low blood pressure?
Do you have high blood pressure?
Are you currently using blood thinners?
Do you have anemia or other blood disorder?
Do you have asthma?
Do you have kidney disease?
Do you have liver disease?
Do you have a hormone deficiency?
Do you have a digestive disorder (celiac, gastric reflux)?
Do you have any neurological disorders (ADD/ADHD)?
Do you get cold sores?
Do you have HIV/AIDS?
Are you currently or have you ever been under the care of mental health specialist?
Are you currently taking antidepressant medication?
Do you have glaucoma?
Do you wear contact lenses?
Is there any chance you may be pregnant?
Are you currently or were you previously a smoker?

Do you have a heart problem or have had a cardiac stent placed within the last 6 months?*

YesNo
Please explain*
Do you have a history or infective endocarditis?*

YesNo
Please explain*
Do you have emphysema, shortness of breath or COPD?*

YesNo
Please explain*
Do you have thyroid, parathyroid or calcium deficiency?*

YesNo
Please explain*
Do you have high cholestorol or take statin drugs?*

YesNo
Please explain*
Do you have diabetes?*

YesNo
What type, and what is your AIC level?*
Do you have a stomach or duodenal ulcer?*

YesNo
Please explain*
Do you have a veneral/communicable disease (ex. Hepatitis, Tuberculosis)?*

YesNo
Please explain*
Do you have osteoporosis/osteopenia?*

YesNo
Please explain*
Do you currently or have past use of bisphosphonates?*

YesNo
Please explain*
Do you have epilepsy or convulsions (seizures)?*

YesNo
Please explain*
Do you have any tumors/abnormal growths?*

YesNo
Please explain*
Are you currently or have you ever had radiation therapy?*

YesNo
Please explain*
Are you currently or have you had chemotherapy or immunosuppressive?*

YesNo
Please explain*
Have you had an prosthesis placed in the past 6 months?*

YesNo
Please explain*
Have you ever had an infection of artificial prosthesis?*

YesNo
Please explain*
Allergies*

NoneAsprinCodeineTetracyclineFluorideIbuprofenPenicillinSulfaLatexAcetaminophenErythromycinLocal AnestheticMetals (Nickel, Gold, Silver)Other
Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment you are currently having, or have had in the past 6 months
Are you taking any medications?*

YesNo
Please list ALL currenty medications and their purpose*
Date*

MonthDayYear
Date
Signature*
Should be Empty:

New Patient Registration

Health History