Patient Registration Form
(* Required Fields)

Patient Information

*Email: *Patient Name:

*Address: *City:

*State: *Zip:

How long at this address:
*Home Phone:
*Birthdate:
Social Security Number:
If patient is a minor, give parent's or guardian's name:
Employer: Work Phone: Occupation:
Time here:
Spouse Name: Spouse Birthdate:
Spouse Social Security Number:
Spouse Employer: Spouse Occupation:
Time here:
How did you learn about our office:
If you were referred by someone, whom may we thank?
 

Responsible Party / Billing Information

Is the patient responsible for financial matters? If not, please fill out the following information for the responsible party.
Responsible Party Name:
Address: City:
State: Zip:
How long at this address:
Home Phone: Work Phone:
Social Security Number:
Birthdate:
Relationship to patient:
Employer: Occupation:
Time here:
Spouse Name:
Spouse Birthdate:
Spouse Social Security Number:
Spouse Employer: Spouse Occupation:
Time here:
 

Insurance Information

Insured's Name:
Insured's Birthdate:
Social Security Number:
Insurance Company: Group Number:
Insurance Phone:
Address: City:
State: Zip:
Do you have dual coverage?
Yes
No
Insured's Name:
Insured's Birthdate:
Social Security Number:
Insurance Company: Group Number:
Insurance Phone:
Address: City:
State: Zip:
 

Medical History

Who is your primary care physician?
Physician's Phone:
How would you describe your overall health?
When was your last physical?
Have you been hospitalized under a physician's care in the last two years?
Yes
No
If so, why?
Please list all medications/drugs you are taking:
Have you ever had an adverse reaction or allergies to any medication or substance? (Please check if allergic.)

Aspirin

Codeine

Erythromycin

Iodine

Latex

Nitrous Oxide

Novocaine

Penicillin

Sulfa Drugs

Tetracycline

Valium

Xylocaine

Others:
Have you ever had any of the following? (Please check all that apply)

Arthritis or Gout

Artificial Joint

Asthma or Allergies

Bleeding Problem or Anemia

Blood Transfusion

Blood disease

Bruise Easily

Cancer

Cold Sores

Congenital Heart Problems

Currently Pregnant

Diabetes

Dizziness or Fainting

Drug/Alcohol Addiction

Eating Disorder

Emphysema

Epilepsy or Seizures

Fever Blisters

Frequent Thirst

Frequent Urination

Glaucoma

HIV-AIDS-ARC

Heart Attack or Stroke

Heart Murmur

Heart Trouble

Heart Valve or Pacemaker

Hepatitis (A)

Hepatitis (B)

Hepatitis (C)

Herpes

High/Low Blood Pressure

Hypoglycemia

Jaw Joint Pain

Kidney or Liver Disease

Lung Disease

Psychiatric Care

Radiation/Chemotherapy

Rheumatic Fever

Sinus Problems

Thyroid Problems

Tuberculosis

Tumor or Growth

Ulcers or G.I. Problems

Use Tobacco

X-ray/Chemotherapy

Do you have any condition or problem not listed about which we should know about? Please explain:
Have you ever been given antibiotics before dental treatment?
Yes
No
Have you recently consumed alcohol?
Yes
No
Have you recently used recreational drugs?
Yes
No
 

Dental History

What are your present dental concerns?
When was your last dental visit?
When were your last dental x-rays?
When was your last cleaning?
Have you avoided regular dental care?
Yes
No
Why?
Do you feel you have active decay?
Yes
No
Do you experience frequent bad breath?
Yes
No
Do you feel you have gum disease?
Yes
No
Have you ever had gum treatments?
Yes
No
How often do you brush?
Floss?
Use other aids?
Are you happy with the appearance of your teeth?
Yes
No
Would you like your teeth to be whiter?
Yes
No
What are your dental expectations?
Name of previous dentist:
City:
State:
Shall we request your records from your previous dentist?
Yes
No
How would you rate your previous dental experience?
 

Nearest Relative

Name of nearest relative not living with you?
Address:
City:
State: