847.249.5700 355 S Greenleaf Ave, Ste EPark City, IL 60085Mon and Fri: 9am-7pm Tue: 9am-2pm Wed and Thu: 9am-5pm Sat: 9am-1pm Sun: Closed

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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

Get in touch

Contact us now

355 S Greenleaf Ave, Ste E, Park City, IL 60085

847.249.5700

Mon and Fri: 9am-7pm Tue: 9am-2pm
Wed and Thu: 9am-5pm Sat: 9am-1pm Sun: Closed

Make Payment Here

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