Patient Registration

Patient Registration Information

Patient First Name

Middle Initial

Patient Last Name

Preferred Name

Gender

Male Female

Date of Birth

Age

SSN

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?

Current Patient Referring Doctor Internet Other

Other

Referral Name

Who will be responsible for your account?

Other

Responsible Person First Name

Responsible Person Last Name

SSN

Date of Birth

Age

Telephone

Address

City

State

Zipcode

Employer

Business Phone

Emergency Contact

First Name

Last Name

Relationship to Patient

Telephone

Insurance Information

We are not part of any dental network and do not accept payment from insurance companies. If you have dental insurance, please fill out below and we will be happy to assist you with the paperwork and submitting your insurance claims on your behalf for reimbursement to you.

Primary Dental Insurance Company

Primary Policy Holder

Relation

Gender

Male Female

SSN

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

Secondary Dental Insurance Company

Do you have secondary dental insurance?

Yes No

Secondary Policy Holder

Relation

Gender

Male Female

SSN

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

Health History

Have you been fully vaccinated against COVID?

Yes No

If so, when?

Have you received the booster shot for COVID?

Yes No

If so, when?

Are you under the care of a physician?

Yes No

If yes, please explain

Physician Name

Physician Phone

Have you been admitted to a hospital or needed emergency care during the past five years?

Yes No

If yes, please explain

Are you taking or have you ever taken any bone medications (antiresorptive for osteoporosis, Paget’s disease, bone pain, hyperkalemia, multiple myeloma, metastatic cancer?)

Yes No

If yes, please explain

Has a physician or previous dentist recommended that you take antibiotics before a dental treatment?

Yes No

If yes, please explain

Have you ever had any complications following dental treatment?

Yes No

If yes, please explain

Date of Last Dental Visit

Reason for this visit

Do you have, or have had, any of the following?

Heart

Coronary Artery Disease/Angina

Yes No

Heart Attack

Yes No

Rheumatic Heart Disease

Yes No

Congestive Heart Failure

Yes No

Heart Murmur

Yes No

Mitral Valve Prolapse

Yes No

Heart Surgery

Yes No

Pacemaker

Yes No

Heart Valve/Damaged Valve

Yes No

Congenital Heart Defect

Yes No

Endocarditis

Yes No

Low Blood Pressure

Yes No

High Blood Pressure

Yes No

Lungs

Asthma

Yes No

Chronic Bronchitis/Emphysema

Yes No

Tuberculosis

Yes No

Respiratory Problems

Yes No

Endocrine

Diabetes

Yes No

Thyroid Problem

Yes No

Adrenal Insufficiency

Yes No

Musculoskeletal

Arthritis

Yes No

Gout

Yes No

Systemic Lupus Erythematosis

Yes No

Bone Disease

Yes No

Artificial Bones

Yes No

Artificial Joints/Valves

Yes No

Rheumatism

Yes No

Cancer

Chemotherapy

Yes No

Tumors

Yes No

Radiation Treatment

Yes No

Cancer

Yes No

Surgery

Yes No

Growths

Yes No

Liver Disease

Hepatitis

Yes No

Jaundice

Yes No

Liver Disease

Yes No

Infectious Disease

Sexually Transmitted Disease

Yes No

AIDS

Yes No

HIV

Yes No

Rheumatic Fever

Yes No

Venereal Disease

Yes No

Blood Disease/Bleeding Problems

Anemia

Yes No

Abnormal Bleeding

Yes No

Hemophilia

Yes No

Blood Transfusion

Yes No

Blood Disease

Yes No

Excessive Bleeding

Yes No

Gastrointestinal

Ulcers

Yes No

GERD

Yes No

Stomach Problems

Yes No

Neurologic

Epilepsy

Yes No

Seizures

Yes No

Fainting

Yes No

Dizziness

Yes No

Stroke

Yes No

Parkinson’s Disease

Yes No

Multiple Sclerosis

Yes No

Mental Disorders

Yes No

Nervous Disorders

Yes No

Head Injuries

Yes No

Renal

Kidney Infection

Yes No

Kidney Disease

Yes No

Dialysis

Yes No

Renal Transplant

Yes No

Head,Ears,Nose and Throat

Sinus Problems

Yes No

Hoarseness/Trouble Swallowing

Yes No

Glaucoma

Yes No

Hay Fever

Yes No

Headache/Migraines

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, over the counter and herbal supplements, 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

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.

Consent For Services

As a condition of your treatment by this office, payment is due at the time of service. The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment. Please be advised failure to confirm will result in cancellation of appointment. If you are unable to keep a scheduled appointment, please give 48 hour advanced notice, to insure that you will not be charged.

Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patients insurance forms or assist in making collections from insurance companies. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.

I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination.

In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder.

I have read the above conditions of treatment and payment and agree to their content.

Form Completion

To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail.

Signature of Patient or Guardian

Clear

Clear

Date

If Patient is a Minor

Form signed by:

Relationship to Patient: