Patient Registration

PATIENT REGISTRATION INFORMATION

Patient First Name

Middle Initial

Patient Last Name

Date of Birth

Preferred Name

Gender

Male Female

Social Security #

Home Phone

Cell Phone

Email

Address

City

State

Zip Code

If college student

Full Time Part Time

Name of School

City

State

Patient or Parent/Guardian’s Employer

Work Phone

Work Address

City

State

Zip Code

Spouse or Parent/Guardian’s Name

Employer

Work Phone

How did you find our practice?

Other

Referral Name

Responsible Party

Other

Responsible Person First Name

Responsible Person Last Name

Social Security #

Date of Birth

Driver's License

Telephone

Address

City

State

Zip Code

Employer

Work Phone

Emergency Contact

First Name

Last Name

Telephone

Relationship to Patient

Insurance Information

Primary Dental Insurance Company

Name of Insured

Name of Insured

Relationship to Patient

Birth Date

Social Security #

Date Employed

Name of Employer

Work Phone

Work Address

City

State

Zip Code

Insurance Co.

Phone

Group #

Policy/ID #

Insurance Address

City

State

Zip Code

Do you have additional dental insurance?

Yes No

Secondary Dental Insurance Company

Name of Insured

Name of Insured

Relationship to Patient

Insured Birth Date

Social Security #

Date Employed

Name of Employer

Work Phone

Work Address

City

State

Zip Code

Insurance Co.

Phone

Group #

Policy/ID #

Address

City

State

Zip Code

Health History

Have you seen a physician for a medical condition in the last 6 months?

Yes No

If yes, please explain

Physician Name

Physician Phone

Have you had an operation, illness or been hospitalized in the last five years?

Yes No

If yes, please explain

Have you ever been instructed to pre-medicate with antibiotics prior to dental treatment for any health related condition such as heart murmur, artificial joints, rheumatic fever, etc.

Yes No

If yes, please explain

Do you wish to speak to the doctor privately about anything?

Yes No

Have you had or do you currently have the following:

CARDIOVASCULAR (Heart)

Heart Attack

Yes No

If so when?

High Blood Pressure

Yes No

Angina

Yes No

If so when?

Low Blood Pressure

Yes No

Damaged Heart Valves

Yes No

Describe

Heart Murmur

Yes No

Congenital Heart Defect

Yes No

Pacemaker

Yes No

Mitral Valve Prolapse

Yes No

Heart Disease

Yes No

Irregular Heartbeat

Yes No

Rheumatic Fever

Yes No

RESPIRATORY (Breathing)

Bronchitis

Yes No

Chronic Cough

Yes No

Sinus Problems

Yes No

Allergies

Yes No

Respiratory Problems

Yes No

Tuberculosis

Yes No

Asthma

Yes No

Use inhaler

Yes No

How often?

ENDOCRINE (Hormones)

Diabetes

Yes No

Take insulin

Yes No

Hypoglycemia

Yes No

Thyroid Disease

Yes No

Hyperthyroid

Yes No

Hypothyroid

Yes No

Hives or Skin Rash

Yes No

Rheumatism

Yes No

SKIN/MUSCULOSKELETAL

Arthritis

Yes No

Back Problems

Yes No

Head Injuries

Yes No

Osteoporosis

Yes No

Artificial Joint

Yes No

If so where and when?

NERVES & SENSORY

Epilepsy or Seizures

Yes No

Fainting

Yes No

Dizziness

Yes No

Nervous Disorders

Yes No

Numbness or Tingling

Yes No

GASTROINTESTINAL (Digestive)

Gastric Reflux

Yes No

Gastric Bypass Surgery

Yes No

Stomach Problems

Yes No

Liver Disease

Yes No

Ulcers

Yes No

Hepatitis

Yes No

If so type and when?

URINARY

Kidney Disease

Yes No

HEMATOLOGIC (Blood)

Stroke

Yes No

If so, when?

Anemia

Yes No

Excessive Bleeding

Yes No

AIDS

Yes No

HIV

Yes No

Blood Disease

Yes No

OTHER CONDITIONS

Depression

Yes No

Eating Disorders

Yes No

Panic Attacks

Yes No

Mental Disorders

Yes No

Glaucoma

Yes No

Excessive Snoring

Yes No

Cold Sores

Yes No

Alcohol Abuse

Yes No

Drug Abuse

Yes No

Cortisone Treatment

Yes No

Radiation Treatment

Yes No

If so where?

Cancer

Yes No

If so type

Tumors

Yes No

If so type

Use Tobacco

Yes No

Smoke Dip/Chew Vape

How long? How much?

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

Are you taking, or supposed to be taking, any medication?

Yes No

Are you taking blood thinners?

Yes No

Are you currently or have you ever taken drugs to treat osteoporosis?

Yes No

Please list all prescription and non-prescription drugs as well as any herbal supplements
(include medication name, dosage and frequency):

Allergies/ Reactions

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

Aspirin

Yes No

Dental Anesthetics

Yes No

Sulfa Drugs

Yes No

Codeine

Yes No

Penicillin

Yes No

Latex

Yes No

Metal

Yes No

Erythromycin

Yes No

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

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 certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health.

Signature of Patient, Parent or Guardian:

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Clear

Date

If Patient is a Minor

Form signed by:

Relationship to Patient:

Online Signature×

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