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About Us
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Family Dentistry
Cosmetic Dentistry
Pediatric Dentistry
Teeth Whitening
Tooth Extraction
Wisdom Teeth Removal
Root Canal Therapy
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Dental Exam
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Dental Implants
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Patient Registration Form
PATIENT INFORMATION
First Name
Last Name
Date of Birth
Address
City
Postal Code
Home Phone
Cell Phone
Email
Where did you hear about us?
Family/Friend
Online Search
Social Media
Newspapers/Magazines
Other
In case of emergency please contact:
Emergency Contact Number
WORK INFORMATION
Employer
Occupation
Work Phone
Address
if this form is filled for another person write the guardian (responsible person) name below
INSURANCE INFORMATION
Primary Insured
Date of Birth
Employer
Insurance Company
Group / Policy Number
ID / Certificate Number
If covered under spouse’s plan as secondary coverage:
Secondary Insured
Date of Birth
Employer
Insurance Company
Group / Policy Number
ID / Certificate Number
MEDICAL HISTORY
Name of Physician
Address of Physician
Office Phone Number
Are you currently under medical treatment?
Yes
No
Reason (if yes)
Have you had an allergic or unusual reaction to any of the following?
(Leave blank if all answers are No)
Aspirin
Yes
No
Codeine
Yes
No
Dental Anesthetic
Yes
No
Penicillin
Yes
No
Other
FOR WOMEN ONLY
Are you Pregnant?
Yes
No
If yes, Expected date of delivery
Have you ever been treated for any of the following?
(Leave Blank if all answers are No)
Anemia
Yes
No
Asthma
Yes
No
Diabetes
Yes
No
Emphysema
Yes
No
Epilepsy
Yes
No
Glaucoma
Yes
No
Hay Fever
Yes
No
Heart Murmurs
Yes
No
Hepatitis
Yes
No
Jaundice
Yes
No
Kidney Disease
Yes
No
Rheumatic Fever
Yes
No
Sinus Trouble
Yes
No
Stroke
Yes
No
Tuberculosis
Yes
No
Ulcers
Yes
No
Venereal Disease
Yes
No
Other
Please answer all questions below:
Have you ever been treated for AIDS-related complex?
Yes
No
Details
Are you taking any medications? If so, what are they?
Yes
No
Medications
Do you have heart trouble? If so, what kind?
Yes
No
Details
Do you have high or low blood pressure? Is it controlled?
Yes
No
Details
Have you ever been required to take prophylactic antibiotics prior to dental treatment?
Yes
No
Details
Do you use tobacco products? If so, how often?
Yes
No
Details
Are you subject to fainting or dizziness? If so, how often?
Yes
No
Details
Have you ever had cancer or a tumor? If so, how was it treated?
Yes
No
Details
Have you ever had any major operations? If so, what kind?
Yes
No
Details
Have you ever been involved in a serious accident?
Yes
No
Details
Do you bruise or bleed easily?
Yes
No
Details
Have you recently had a communicable disease (i.e. Mumps, Measles, etc.)?
Yes
No
Details
Dental History
Previous Dentist
Address
Phone Number
Fax Number
Date of Last Visit
In past years have you been to a dentist on a regular basis? If so how often?
Are you presently in any dental pain?
Is any part of your mouth sensitive to temperature, pressure or sweets?
Have you ever had orthodontic treatment?
Do your gums bleed when brushing your teeth?
Do you have an unpleasant taste or odor in your mouth?
Do you get growth or swelling after tooth extractions? If so, for how long?
Have you ever gotten food stuck between your teeth?
Do you awaken with pain in your teeth or jaws?
Do you have frequent headaches or facial pain?
Are you aware of jaw clicking or popping while eating or yawning?
Do you ever get cold sores or fever blisters?
What is your major dental concern at this time?
Name of Patient (or the responsible person)
Date Signed
Message
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