About us

NEW PATIENTS

In order to ensure maximum oral health and allow us to prescribe the proper medications, it is very important that we know all medical and dental information about you.

REVIEWS





REGISTRATION AND HEALTH INFORMATION FORM


Please check every box on this form, even if the answer is “N/A” (not applicable).  This information will be kept in the strictest confidence.

You also should know that changes in other parts of your body may affect the oral cavity and what dental treatment can be done, even if they seem unconnected.  Cardiac (heart) problems, artificial joints and diabetes are just some examples.






    1. Patient Information

    Your Name*
    Address*
    City*
    State
    Zip
    Birthdate
    Age
    Sex
    Marital Status
    Social Security #
    Occupation
    Business Employer
    Spouse’s Name
    Spouse’s Occupation
    Spouse’s Employer

    Children

    Child 1

    Name
    Date of Birth

    Child 2

    Name
    Date of Birth

    Child 3

    Name
    Date of Birth

    Child 4

    Name
    Date of Birth

    Child 5

    Name
    Date of Birth

    Child 6

    Name
    Date of Birth
     
     


     

    2. Insurance

    Responsible Party
    SS #
    Date of Birth
    Relationship to Patient
    Insurance Company
    ID Number
    Group Number
     
     


     

    3. Phone Numbers

    Home
    Work
    Ext.
    Cellphone
    Your Email*
     
       How would you like to be contacted? Home PhoneWork PhoneCell PhoneEmail
     

    Spouse’s Work
    Family Physician
    Physician’s Phone

    In case of emergency, contact:

    Name
    Relationship
    Home Phone
    Work Phone
     
     


     

    Who may we thank for referring you?
     
     


    4. Assignment & Release

    I certify that I (or my dependent) have insurance coverage as indicated and I assign directly to this office all insurance benefits otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

    Responsible Party
    Relationship to minor (if applicable)
    Date
     
     


    1. Dental History

    Reason for today’s visit:
    Former Dentist
    Last dental visit
    Last X-rays

    Check box to indicate if you presently have or previously had the following

    Bad breath
    YesNo
    Bite your lips/cheeks
    YesNo
    Bleeding gums
    YesNo
    Blisters on lips/mouth
    YesNo
    Chew on side of mouth
    YesNo
    Dry mouth
    YesNo
    Food collects between teeth
    YesNo
    Grinding teeth
    YesNo
    Gums swollen or tender
    YesNo
    Jaw pain or tiredness
    YesNo
    Mouth breathing
    YesNo
    Night guard appliance
    YesNo
    Orthodontic treatment
    YesNo
    Pain around ear
    YesNo
    Periodontal (gum) treatment
    YesNo
    Sensitivity to cold
    YesNo
    Sensitivity to heat
    YesNo

    Have you experienced

    Clicking popping of the jaw
    YesNo
    Pain (joint, ear, side of face)
    YesNo
    Difficulty opening or closing the mouth?
    YesNo
    How often do you floss?

     

    How often do you brush?
    Do you require antibiotics before dental treatment?
    YesNo
    Are you currently in pain?
    YesNo
    Have you any serious/difficult problem associated with any previous dental work?
    YesNo
    Do you like your smile?
    YesNo
    Do you feel nervous about having dental treatment?
    YesNo
    Have you ever had a bad experience in a dental office?
    YesNo
    If yes, please describe

     

    Is there anything else about having dental treatment that you would like us to know?
     
     


    2. Medical History

     
       Your current physical history is: GoodFairPoor
     

    Are you currently under the care of a Physician?
    YesNo
    Please explain:

     

    Are you currently taking any perscription/over the counter drugs?
    YesNo
    Please list:

     

    Do you currently use a CPAP appliance?
    YesNo
    Do you smoke/use other tobacco products?
    YesNo

    For Women

    Are you taking birth control pills?
    YesNo
    Are you pregnant?
    YesNo
    Are you nursing?
    YesNo

     
    Do you have or have you ever had any of the following diseases or medical problems?

    Abnormal Bleeding
    YesNo
    Acid Reflux/GERD
    YesNo
    Alcohol/Drug Abuse
    YesNo
    Alzheimer’s Disease
    YesNo
    Anemia
    YesNo
    Arthritis
    YesNo
    Artificial Bone/joint/valve
    YesNo
    Asthma
    YesNo
    Blood Transfusion
    YesNo
    Bruise Easily
    YesNo
    Cancer/Chemotherapy
    YesNo
    Colitis
    YesNo
    Diabetes
    YesNo
    Difficulty Breathing
    YesNo
    Emphysema
    YesNo
    Epilepsy
    YesNo
    Fainting Spells
    YesNo
    Frequent Headaches
    YesNo
    Glaucoma
    YesNo
    Hay Fever
    YesNo
    Heart Problems
    YesNo
    Heart Murmur
    YesNo
    Hemophilia
    YesNo
    Hepatitis A/B/C
    YesNo
    Herpes/Fever Blister
    YesNo
    High Blood Pressure
    YesNo
    HIV/Aids
    YesNo
    Hospitalized for any reason
    YesNo
    Joint Replacement
    YesNo
    Kidney Problems
    YesNo
    Liver Disease
    YesNo
    Low Blood Pressure
    YesNo
    Mitral Valve Prolapse
    YesNo
    Nervous/Anxiety
    YesNo
    Pacemaker
    YesNo
    Psychiatric/Psychology care
    YesNo
    Radiation Treatment
    YesNo
    Rheumatic/Scarlet Fever
    YesNo
    Seizures
    YesNo
    Sinus Pressure
    YesNo
    Stroke
    YesNo
    Thyroid Problems
    YesNo
    Tuberculosis (TB)
    YesNo
    Tumor or Growth
    YesNo
    Ulcers
    YesNo
    Venereal Disease
    YesNo
    Do you have or have you had any disease or condition not listed
    YesNo

     
    Are you Allergic to any of the following?

    Aspirin
    YesNo
    Codeine
    YesNo
    Dental Anesthetics
    YesNo
    Latex
    YesNo
    Metals
    YesNo
    Penicillin
    YesNo
    Tetracycline
    YesNo
    Please list any other drugs/materials that you are allergic to:
     
     


    3. Certification

     
    I certify that the answers given are correct to the best of my knowledge.

    Signature
    Relationship to minor (if applicable)
    Date





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