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New Patient Registration Form
1
Patient Information
*
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Mr
Mrs
Ms
Dr
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Please Select
Mr
Mrs
Ms
Dr
Prefix
Full Name
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Male
Female
Please Select
Please Select
Male
Female
Gender
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Single
Married
NA
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Please Select
Single
Married
NA
Marital Status
Occupation
SSN
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2
{patientInformation3[4]} Date of Birth
*
This field is required.
Patient's birthdate
-
Birth Date
Month
Day
Year
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3
Todays Date
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Date
Month
Day
Year
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4
Contact Information
Please enter your email
Please enter your mobile phone
Please enter your work phone
Please type your address
Zip Code
City
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Alabama
Alaska
Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Marianas Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Virgin Islands
Washington
West Virginia
Wisconsin
Wyoming
Texas
Please Select
Alabama
Alaska
Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Marianas Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Virgin Islands
Washington
West Virginia
Wisconsin
Wyoming
State
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5
Is {patientInformation3[4]} have insurance?
*
This field is required.
YES
NO
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6
Insurance Details
Name of Insure Person
Group #
Member ID
Insured's Employers Name
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Self
Spouse
Child
Other
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Please Select
Self
Spouse
Child
Other
Patient's relationship to insured
Insurance Plan Name
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7
Insurance Details 2
Employer Name
Employer Full Address
Employer phone number
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8
Whom may we thank for referring you to our practice?
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9
Name of Physician
Physician phone #
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10
Date of last physical exam
-
Date
Month
Day
Year
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11
Are you currently under physician care?
*
This field is required.
No
Other
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12
Are you currently taking any medication?
*
This field is required.
This is also includes supplements and vitamins
Yes
No
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13
List medications details
Please list in details the medications, the reasons for taking it and indicate if you take it in AM or PM
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14
What is the reason for your visit?
*
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15
Do you have or have you had any of the following conditions?
*
This field is required.
Yes
No
Has your doctor stated that you need to pre-medicate with antibiotics before dental visits?
Row 0, Column 0
Row 0, Column 1
Artificial/Damaged heart valves
Row 1, Column 0
Row 1, Column 1
Congenital heart defect
Row 2, Column 0
Row 2, Column 1
Prosthetic joint
Row 3, Column 0
Row 3, Column 1
Sinus problems
Row 4, Column 0
Row 4, Column 1
Asthma? Other lung/breathing problems
Row 5, Column 0
Row 5, Column 1
Diabetes or high glucose
Row 6, Column 0
Row 6, Column 1
Hepatitis, jaundice, other liver dysfunction
Row 7, Column 0
Row 7, Column 1
HIV
Row 8, Column 0
Row 8, Column 1
Sexually-transmitted disease
Row 9, Column 0
Row 9, Column 1
Thyroid problems
Row 10, Column 0
Row 10, Column 1
Arthritis? Swollen joints
Row 11, Column 0
Row 11, Column 1
Tuberculosis
Row 12, Column 0
Row 12, Column 1
Persistent cough that produces blood
Row 13, Column 0
Row 13, Column 1
Stomach ulcers or other Gastrointestinal problem
Row 14, Column 0
Row 14, Column 1
Kidney problems
Row 15, Column 0
Row 15, Column 1
Epilepsy or seizures
Row 16, Column 0
Row 16, Column 1
Cancer
Row 17, Column 0
Row 17, Column 1
Low immune function
Row 18, Column 0
Row 18, Column 1
Bleeding disorders
Row 19, Column 0
Row 19, Column 1
Are you wearing contact lenses?
Row 20, Column 0
Row 20, Column 1
Do you have osteoporosis or osteopenia?
Row 21, Column 0
Row 21, Column 1
Our office offers IV Sedation (Twilight Sleep). Would you like to discuss this as an option?
Row 22, Column 0
Row 22, Column 1
Has your doctor stated that you need to pre-medicate with antibiotics before dental visits?
Artificial/Damaged heart valves
Congenital heart defect
Prosthetic joint
Sinus problems
Asthma? Other lung/breathing problems
Diabetes or high glucose
Hepatitis, jaundice, other liver dysfunction
HIV
Sexually-transmitted disease
Thyroid problems
Arthritis? Swollen joints
Tuberculosis
Persistent cough that produces blood
Stomach ulcers or other Gastrointestinal problem
Kidney problems
Epilepsy or seizures
Cancer
Low immune function
Bleeding disorders
Are you wearing contact lenses?
Do you have osteoporosis or osteopenia?
Our office offers IV Sedation (Twilight Sleep). Would you like to discuss this as an option?
Yes
Row 0, Column 0
No
Row 0, Column 1
Yes
Row 1, Column 0
No
Row 1, Column 1
Yes
Row 2, Column 0
No
Row 2, Column 1
Yes
Row 3, Column 0
No
Row 3, Column 1
Yes
Row 4, Column 0
No
Row 4, Column 1
Yes
Row 5, Column 0
No
Row 5, Column 1
Yes
Row 6, Column 0
No
Row 6, Column 1
Yes
Row 7, Column 0
No
Row 7, Column 1
Yes
Row 8, Column 0
No
Row 8, Column 1
Yes
Row 9, Column 0
No
Row 9, Column 1
Yes
Row 10, Column 0
No
Row 10, Column 1
Yes
Row 11, Column 0
No
Row 11, Column 1
Yes
Row 12, Column 0
No
Row 12, Column 1
Yes
Row 13, Column 0
No
Row 13, Column 1
Yes
Row 14, Column 0
No
Row 14, Column 1
Yes
Row 15, Column 0
No
Row 15, Column 1
Yes
Row 16, Column 0
No
Row 16, Column 1
Yes
Row 17, Column 0
No
Row 17, Column 1
Yes
Row 18, Column 0
No
Row 18, Column 1
Yes
Row 19, Column 0
No
Row 19, Column 1
Yes
Row 20, Column 0
No
Row 20, Column 1
Yes
Row 21, Column 0
No
Row 21, Column 1
Yes
Row 22, Column 0
No
Row 22, Column 1
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16
If you answered Yes to any of the above questions, please provide a brief history with relevant dates.
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17
Do you take any blood thinners?
*
This field is required.
No
Other
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18
Date and result of most recent HbA1c:
-
Date
Month
Day
Year
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19
Psychiatric care?
*
This field is required.
No
Other
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20
Do you smoke or use other forms of tobacco?
*
This field is required.
No
Other
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21
Have you had any general surgeries?
*
This field is required.
No
Other
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22
Do you take or have you ever taken any bisphosphonate (i.e. Fosamax, Actonel, Boniva, etc)? *
*
This field is required.
No
Other
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23
When was your last dental cleaning?
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24
How often do you have cleanings?
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25
Have you had any serious problems with dental treatment?
*
This field is required.
No
Other
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26
Do you have any medical disease or condition that is not listed?
*
This field is required.
No
Other
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27
Are there any medications you cannot or prefer not to take?
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28
Do you have an allergy to or have you had a bad reaction to:
*
This field is required.
Yes
No
Local anesthetics (i.e. Novocain)
Row 0, Column 0
Row 0, Column 1
Penicillin or other antibiotics
Row 1, Column 0
Row 1, Column 1
Aspirin
Row 2, Column 0
Row 2, Column 1
Codeine or other narcotics
Row 3, Column 0
Row 3, Column 1
General anesthetics/sedation medication
Row 4, Column 0
Row 4, Column 1
Sulfite (red wine)
Row 5, Column 0
Row 5, Column 1
Iodine
Row 6, Column 0
Row 6, Column 1
Other medication allergies:
Row 7, Column 0
Row 7, Column 1
Local anesthetics (i.e. Novocain)
Penicillin or other antibiotics
Aspirin
Codeine or other narcotics
General anesthetics/sedation medication
Sulfite (red wine)
Iodine
Other medication allergies:
Yes
Row 0, Column 0
No
Row 0, Column 1
Yes
Row 1, Column 0
No
Row 1, Column 1
Yes
Row 2, Column 0
No
Row 2, Column 1
Yes
Row 3, Column 0
No
Row 3, Column 1
Yes
Row 4, Column 0
No
Row 4, Column 1
Yes
Row 5, Column 0
No
Row 5, Column 1
Yes
Row 6, Column 0
No
Row 6, Column 1
Yes
Row 7, Column 0
No
Row 7, Column 1
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29
Women
Yes
No
Are you, or do you think that you might be pregnant?
Row 0, Column 0
Row 0, Column 1
Do you take birth control pills?
Row 1, Column 0
Row 1, Column 1
Are you nursing?
Row 2, Column 0
Row 2, Column 1
Do you have problems with your menstrual period?
Row 3, Column 0
Row 3, Column 1
Are you, or do you think that you might be pregnant?
Do you take birth control pills?
Are you nursing?
Do you have problems with your menstrual period?
Yes
Row 0, Column 0
No
Row 0, Column 1
Yes
Row 1, Column 0
No
Row 1, Column 1
Yes
Row 2, Column 0
No
Row 2, Column 1
Yes
Row 3, Column 0
No
Row 3, Column 1
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30
Men
Yes
No
Do you take Viagra, Cialis or Levitra?
Row 0, Column 0
Row 0, Column 1
Do you take Viagra, Cialis or Levitra?
Yes
Row 0, Column 0
No
Row 0, Column 1
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31
Disclaimer
I certify that I have read and understand the above. I acknowledge that my questions regarding this form have been answered to my satisfaction. I will not hold my dentist or any other member of the office staff responsible for errors or omissions that I may have made in the completion of this form. I acknowledge that if I make omissions or false statements, my health may be put at risk.
Signature of Patient or Patient's Representative:
Relationship to Patient (If not signed by the Patient):
Date
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32
Financial Policy
I certify that I have read and agree to the financial policy.
Name Patient or Patient's Representative:
Date
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33
Photography Policy
As described, I authorize Dr. Salha to use my photographs as needed in order to communicate with other doctors who are involved in my care. At no time will any identifying or full face photo be shared.
Clear
Signature of Patient or Patient's Representative:
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34
Privacy Policy
My signature acknowledges that I have been provided with a copy of the Notice of Privacy Practices.
Clear
Signature of Patient or Patient's Representative:
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