Patient Registration

PATIENT REGISTRATION

First Name

Middle Initial

Last Name

Gender

Male Female

Birth Date

Age

Marital Status

Single Married Divorced Widowed

Address

City

State

ZIP Code

Social Security #

Pre-payment required if SSN not provided

Email

Please note that many dental insurance companies still use social security numbers to verify identity, coverage and eligibility for benefits. Until this changes, it is our office policy that any patient that does not wish to provide this information be expected to pre-pay for all dental services rendered.

Cell Phone

Home Phone

Work Phone

Employment Status

Employer

Occupation

RESPONSIBLE PARTY

Please select if self and skip to the next section

First Name

Middle Initial

Last Name

Gender

Male Female

Birth Date

Age

Marital Status

Single Married Divorced Widowed

Address

City

State

ZIP Code

Social Security #

Pre-payment required if SSN not provided

Email

Cell Phone

Home Phone

Work Phone

Employment Status

Employer

Relationship to Patient

INSURANCE INFORMATION

Do you have dental insurance?

Yes No

PRIMARY DENTAL INSURANCE COMPANY

Primary Policy Holder

Primary Policy Holder

Primary Policy Holder

Social Security #

Pre-payment required if SSN not provided

Birth Date

Relation to Patient

Self Spouse Child Other

Other

Telephone

Address

City

State

ZIP Code

Primary Policy Holder Employer

Insurance Co. Name

Insurance Co. Phone

Policy I.D. #

Group #

Plan Name

Do you have secondary insurance?

Yes No

SECONDARY DENTAL INSURANCE COMPANY

Secondary Policy Holder

Secondary Policy Holder

Secondary Policy Holder

Social Security #

Pre-payment required if SSN not provided

Birth Date

Relation to Patient

Self Spouse Child Other

Other

Telephone

Address

City

State

ZIP Code

Secondary Policy Holder Employer

Insurance Co. Name

Insurance Co. Phone

Policy I.D. #

Group #

Plan Name

EMERGENCY CONTACT

First Name

Last Name

Phone

Relationship to Patient

Please note that all minors must be accompanied by an adult to their dental appointments. If you would like for an adult other than a parent or legal guardian to accompany your child to their dental appointments, please list them below in order to authorize them to serve as proxy decision makers for your child’s dental care and services.

Name

Relationship to Patient

Name

Relationship to Patient

Name

Relationship to Patient

WHO CAN WE THANK FOR REFERRING YOU TO OUR PRACTICE?

Other

Referral Name

HEALTH HISTORY

Are you currently under medical treatment?

Yes No

If yes, please describe

Physician Name

Physician Phone

Do you take antibiotic pre-medication prior to dental appointments?

Yes No

If yes, please list antibiotic

Reason prescribed

Preferred Pharmacy

Pharmacy Location

Pharmacy Phone

Are you pregnant?

Yes No

If yes, number of weeks

Are you nursing?

Yes No

Have you had any of the following health problems either now or in the past?

Abnormal Bleeding

Yes No

Alcohol or Drug Abuse

Yes No

Allergies

Yes No

Anemia

Yes No

Arthritis

Yes No

Artificial Heart Valve

Yes No

Artificial Joint

Yes No

Asthma

Yes No

Bacterial Endocarditis

Yes No

Bisphosphonate Use

Yes No

Blood Thinner Use

Yes No

Cancer or Chemotherapy

Yes No

Chest Pain

Yes No

Cold Sores or Fever Blisters

Yes No

Congenital Heart Defect

Yes No

Congestive Heart Failure

Yes No

Diabetes

Yes No

Dialysis

Yes No

Difficulty Breathing

Yes No

Eating Disorder

Yes No

Emphysema or COPD

Yes No

Epilepsy or Seizures

Yes No

Fainting Spells

Yes No

Fibromyalgia

Yes No

Frequent Headaches

Yes No

Glaucoma

Yes No

HIV+ AIDS

Yes No

Hearing Loss

Yes No

Heart Attack

Yes No

Heart Disease

Yes No

Heart Surgery

Yes No

Hemophilia

Yes No

Hepatitis

Yes No

High Blood Pressure

Yes No

Kidney Problems

Yes No

Kidney Transplant

Yes No

Liver Disease

Yes No

Low Blood Pressure

Yes No

Mitral Valve Prolapse

Yes No

Pacemaker or Defibrillator

Yes No

Pain in Jaw Joints

Yes No

Psychiatric Problems

Yes No

Radiation Therapy

Yes No

Sickle Cell Disease

Yes No

Sinus Problems

Yes No

Stroke

Yes No

Thyroid Problems

Yes No

Tuberculosis

Yes No

Ulcers

Yes No

Venereal Disease

Yes No

Do you smoke?

Yes No

Do you drink alcohol?

Yes No

If yes, how much per week?

For how long?

Tobacco Cannabis

If yes, how much per week?

For how long?

Do you have a history of COVID-19 infection?

Yes No

Have you been vaccinated against COVID-19?

Yes No

Other problem or condition is not listed?

Yes No

MEDICATIONS

Please list all medications, over the counter and herbal supplements, that you are currently taking (or supposed to be taking) including name, dosage and reason prescribed.

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

Latex

Yes No

Penicillin

Yes No

Tetracycline

Yes No

Other allergies not listed

Yes No

FORM COMPLETION

To the best of my knowledge, the questions on this form have been accurately answered. I understand 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.

Signature of Patient, Parent or Guardian:

Clear

Clear

Date:

IF PATIENT IS A MINOR

Form signed by:

Relationship to Patient:

Online Signature×

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