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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