Patient Registration

PATIENT REGISTRATION INFORMATION

Patient First Name

Middle Initial

Patient Last Name

Nickname

Sex

Male Female

Date of Birth

Age

Social Security #

Home Phone

Cell Phone

Address

City

State

Zip Code

Marital Status

Email

Business Email

Employer

Occupation

Business Phone

Address

City

State

Zip Code

Who can we thank for referring you to our practice?

Other

Referral Name

Emergency Contact

First Name

Last Name

Telephone

Relationship to Patient

Responsible Party (if self is selected, please skip to the next section)

Other

Responsible Person First Name

Responsible Person Last Name

Birth Date

Social Security #

Home Phone

Cell Phone

Address

City

State

Zip Code

Email

Business Email

Employer

Business Telephone

Address

City

State

Zip Code

Insurance Information

Primary Dental Insurance Company

Primary Policy Holder

Relation

Gender

Male Female

S.S. #

Date of Birth

Address

City

State

Zip Code

Telephone

Primary Policy Holder Employer

Business Telephone

Insurance Co. Name

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

S.S. #

Date of Birth

Address

City

State

Zip Code

Telephone

Secondary Policy Holder Employer

Business Telephone

Insurance Company Name

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

Phone

Address

City

State

Zip Code

Dentist Email

Date of last dental care

Date of last x-rays

Please check all that apply

How often do you brush?

How often do you floss?

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

Medical History

Physician Name

Phone

Address

City

State

Zip Code

Physician Email

Date of last visit

Are you currently under the care of a physician?

Yes No

If yes, please describe

Have you ever had a blood transfusion?

Yes No

If yes, give approximate dates

Have you had or do you currently have the following:

* Pre-Med - Amox

Yes No

* Pre-Med - Clindamycin

Yes No

* Pre-Med - Keflex

Yes No

* Pre-Med - Other

Yes No

Alzheimer’s Disease

Yes No

Anemia

Yes No

Angina

Yes No

Arthritis or Gout

Yes No

Artificial Heart Valve

Yes No

Artificial Joints

Yes No

Asthma

Yes No

Blood Disease

Yes No

Cancer

Yes No

Chemical Dependency

Yes No

Chemotherapy

Yes No

Congenital Heart Disease

Yes No

Cortisone Treatments

Yes No

Diabetes

Yes No

Emphysema

Yes No

Epilepsy or Seizures

Yes No

Excessive Bleeding

Yes No

Fibromyalgia

Yes No

Glaucoma

Yes No

Heart Attack/Failure

Yes No

Heart Disease

Yes No

Heart Murmur

Yes No

Hepatitis A

Yes No

Hepatitis B or C

Yes No

Herpes

Yes No

High Blood Pressure

Yes No

HIV or AIDS

Yes No

Kidney Disease

Yes No

Liver Disease

Yes No

Low Blood Pressure

Yes No

Lupus

Yes No

Mitral Valve Prolapse

Yes No

Multiple Sclerosis

Yes No

Nervous Disorders

Yes No

Pacemaker

Yes No

Psychiatric Care

Yes No

Radiation Treatment

Yes No

Rheumatic Fever

Yes No

Stroke

Yes No

Thyroid Conditions

Yes No

Tuberculosis

Yes No

Tumors

Yes No

Ulcers

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

Have you ever taken Fen-Phen/ Redux?

Yes No

Have you ever used a Bisphosphonate medication (Fosamax, Actonel, Atelvia, Didronel, Boniva)?

Yes No

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:

Acetaminophen

Yes No

Ceclor

Yes No

Clindamycin/Erythromycin

Yes No

Latex

Yes No

Sulfa

Yes No

Aspirin

Yes No

Ceftin

Yes No

Codeine

Yes No

Penicillin/Amoxicillin

Yes No

Tetracycline

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 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. If there is any change in my medical status, I will inform the dentist.

I authorize my insurance company to pay to the dentist or dental group 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.

Signature of Patient or Guardian

Clear

Clear

Date

If Patient is a Minor

Form signed by:

Relationship to Patient: