Patient Registration

Patient Name:
DOB:
AGE:
Residence Address:
City:
State:
Zip:
Phone #(H):
(C):
Single:
Married:
Divorced:
Separated:
Widowed:
Your SS #:
Email:
Employed By:
Phone #:
Spouse Name:
Phone #:
Spouse SS #:
DOB:
AGE:

Dental Insurance

Name of Policy Holder:
Employer:
Name of Dental Insurance:
Member ID:
Group Number:
Dental Insurance Phone #:
Referred By:
1) What is your major concern about your teeth?:
2) When was your last dental visit?:
Recent --- why did you leave your last Dentist?:
Long Time --- What has kept you away so long? :
3) Do you have any missing teeth?:
Yes No
Have you had them replaced?:
Yes No
How do you feel about that? :
4) Do your gums bleed easily?:
Yes No
5) Do you still have your wisdom teeth?:
Yes No
6) Do you like your smile?:
Yes No
If not, why not? :
7) Would you be interested in Botox or Filler?:
Yes No Maybe

Medical Information

Questionaire
Are you under a physician's care now?
Yes
No
If yes
Have you ever been hospitalized or had a major operation?
Yes
No
If yes
Have you ever had a serious head or neck injury?
Yes
No
If yes
Can you be pregnant?
Yes
No
If yes
Have you ever taken Fosamax, Boniva, Actonel or any
other medication containing bisphosphonates?
Yes
No
If yes
Do you use tobacco?
Yes
No
If yes
Acrylic
Yes No
Aspirin
Yes No
Codeine
Yes No
Latex
Yes No
Local Anesthetics
Yes No
Metal
Yes No
Penicillin
Yes No
Sulfa Drugs
Yes No
other allergies?
Yes
No
If yes
Do you use controlled substances?
Yes
No
If yes

Health History

Check only the ones that apply

Aids / Hiv Positive
Angina
Asthma
Bruise easily
Cold sores / Fever blisters
Epilepsy or seizures
Heart murmur
High blood pressure
Kidney problems
osteoporosis
stroke
Alzheimer's disease
Arthritis / gout
Blood disease
Cancer
Congential heart disorder
Excessive bleeding
Heart Pacemaker
High cholesterol
Leukemia
Pain in jaw joints
Tuberculosis
Anaphylaxis
Artificial Heart Valve
Blood Transfusion
Chemotherapy
Diabetes
Fainting Spells / Dizziness
Heart trouble / disease
Hypoglycemia
Low blood pressure
Radiation Treatments
Tumors or growths
Anemia
Artificial joint
Breathing Problems
Chest Pains
Drug Addition
Heart attack / Failure
Hepatitis b or c
Irregular heartbeat
Mitral Valve prolapse
Sinus trouble
Other
List all medications and / or supplements you are taking

*** All Payments and / or co-payments are due at the time of service ***
* Any x-rays or diagnostic models taken are the property of this office
patients pay for the diagnostic services, not the materials

To the best of my knowledge, the questions on this form have been accurately answered. I undertand that providing incorrect information can be DANGEROUS to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

Patient Name:
Date:
Signature of Patient, Parent or Guardian:

ELECTRONIC SIGNATURE. The above signature is an electronic signature that states you have thoroughly read and properly filled out the form
Date: