Patient Registration

PATIENT REGISTRATION INFORMATION

Patient First Name

Middle Initial

Patient Last Name

Patient Nickname

Gender

Male Female

Date of Birth

Age

SSN

Optional

Driver's License #

Email

Address

City

State

Zipcode

Home Phone

Cell Phone

Marital Status

Employer

Occupation

Business Phone

Who can we thank for referring you to our practice?

Other

Referral Name

RESPONSIBLE PARTY (if self is selected, please skip to the next section)

Other

Responsible Person First Name

Responsible Person Last Name

SSN

Optional

Date of Birth

Age

Telephone

Address

City

State

Zipcode

Employer

Business Phone

Insurance Information

Do you have primary dental insurance?

Yes No

Primary Dental Insurance Company

Primary Policy Holder

Relation

Gender

Male Female

SSN

Optional

Date of Birth

Address

City

State

Zip Code

Telephone

Primary Policy Holder Employer

Business Address

City

State

Zip Code

Business Telephone

Insurance Company Name

Insurance Company Address

City

State

Zip Code

Telephone

Policy I.D. #

Group #

Plan Name

Do you have secondary dental insurance?

Yes No

Secondary Dental Insurance Company

Secondary Policy Holder

Relation

Gender

Male Female

SSN

Optional

Date of Birth

Address

City

State

Zip Code

Telephone

Secondary Policy Holder Employer

Business Address

City

State

Zip Code

Business Telephone

Insurance Company Name

Insurance Company Address

City

State

Zip Code

Telephone

Policy I.D. #

Group #

Plan Name

Dental History

What would you like us to do today?

Are you in dental discomfort today?

Former Dentist

Dentist Phone

Address

City

State

Zipcode

Dentist’s Email

Date of Last Dental Care

Date of Last X-rays

How often do you brush?

How often do you floss?

Do you have problems with any of the following? Please check all that apply.

How do you feel about the appearance of your teeth?

Have you ever experienced an adverse reaction during or in conjunction with a medical or dental procedure?

Yes No

If yes, please explain

Other information about your dental health or previous treatment:

Health History

Are you under the care of a physician? If yes, please complete the line below.

Yes No

Date of last visit?

Physician Name

Physician Phone

Preferred Pharmacy

Pharmacy Location

Pharmacy Phone

Do you have or have you had anaphylaxis?

Yes No

If yes, please list to what

Have you under gone chemotherapy?

Yes No

If yes

Presently In the past Both

Have you had or do you currently have the following:

Pre-Med-Amox

Yes No

Pre-Med-Clind

Yes No

Pre-Med-Other

Yes No

Abnormal Bleeding

Yes No

Alcohol Abuse

Yes No

Allergies

Yes No

Anemia

Yes No

Anxiety Disorder

Yes No

Artificial Joints

Yes No

If yes, what joint?

Arthritis

Yes No

Artificial Heart Valve

Yes No

Asthma

Yes No

Atopic (allergy prone)

Yes No

Back Problems

Yes No

Blood Disease

Yes No

Blood Transfusion

Yes No

Cancer

Yes No

Circulatory Problems

Yes No

Cortisone Treatments

Yes No

Cough, persistent

Yes No

Diabetes

Yes No

Drug Abuse

Yes No

Epilepsy

Yes No

Emphysema

Yes No

Fainting

Yes No

Fever Blisters

Yes No

Frequent Headaches

Yes No

Glaucoma

Yes No

Head Injuries

Yes No

Heart Attack/Failure

Yes No

Heart Defect

Yes No

Heart Disease

Yes No

Heart Murmur

Yes No

Hepatitis A

Yes No

Hepatitis B

Yes No

Hepatitis C

Yes No

High Blood Pressure

Yes No

AIDS/HIV

Yes No

Jaundice

Yes No

Jaw Joint Pain

Yes No

Kidney Disease

Yes No

Liver Disease

Yes No

Low Blood Pressure

Yes No

Mitral Valve Prolapse

Yes No

Pacemaker

Yes No

Psychiatric Care

Yes No

Radiation Treatment

Yes No

Respiratory Problems

Yes No

Rheumatic Fever

Yes No

Rheumatism

Yes No

Seizures

Yes No

Shingles

Yes No

Shortness of Breath

Yes No

Sickle Cell Disease

Yes No

Sinus Problems

Yes No

Sleep Apnea

Yes No

Spina Bifida

Yes No

Stomach/Intestinal Problems

Yes No

Stroke

Yes No

Swelling of feet or ankles

Yes No

Thyroid Problems

Yes No

Tobacco Use

Yes No

Tonsillitis

Yes No

Tuberculosis

Yes No

Tumors/Growths

Yes No

Ulcers

Yes No

Venereal Disease

Yes No

Is there any disease, condition, or problem that you think our office should know about that is not listed above?

Yes No

Please list below

Medications

Please list all medications, that you are currently taking (include medication name, dosage and frequency):

Allergies/ Reactions

Are you allergic to, or had a reaction to any of the following:

Aspirin

Yes No

Codeine

Yes No

Dental Anesthetic

Yes No

Erythromycin

Yes No

Jewelry

Yes No

Latex

Yes No

Metals

Yes No

Penicillin

Yes No

Sulfa drugs

Yes No

Tetracycline

Yes No

Allergy/Reactions not listed above

Yes No

Please list any allergy/reaction that you have or have had that is not listed above.

Additional Notes/Comments

For Women Only

Is there a possibility of pregnancy?

Yes No

If yes, number of weeks

Are you nursing?

Yes No

Are you taking birth control pills?

Yes No

WARNING: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician for assistance regarding additional methods of birth control.

Form Completion

I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate and healthful dental treatment. It is my responsibility to inform the dental office of any changes in my medical status and agree to updating my medical history when requested by the practice.

I authorize the insurance company indicated on this form to pay to the dentist all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions.

I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.

Payment due in full at the time of treatment.

Signature of Patient or Guardian

Clear

Clear

Date

If Patient is a Minor

Form signed by:

Relationship to Patient: