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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