Patient Registration Form

Please complete the following confidential information. 

Step 1: Personal Information

 
Date:    
Middle:
Prefers to be called by:    
   
Fax:  
Cell:  
Birthdate: Age: Sex:
Marital Status:    
Social Security Number:    

Step 2: Dental Insurance

 
Primary Carrier    
Insurance Company: Group Number:  
Employer Name: Insured's Name:  
Date of Birth: Relationship to patient:  
Insured's ID No.: Insured's Social Security Number:  


Secondary Carrier		    
Insurance Company: Group Number:  
Employer Name: Insured's Name:  
Date of Birth: Relationship to patient:  
Insured's ID No.: Insured's Social Security Number:  
 

Step 3: Getting to Know You

 
Is Another Member of your family or relative a patient at our office?
Name: Relationship:  

You were referred to is by: 		   
Your former address:    
City.: State: Zip:

Person to contact for emergency: 		   
Phone: Address:  
City.: State: Zip:

Closest relative not living with you: 		   
Phone: Address:  
City.: State: Zip:

Step 4: Account Details

 
Person responsible for account:
Name: Relationship: Social Security No.
Address:    
City.: State: Zip:
Phone :    
You:
Name: Occupation: Employer's Name
Address:    
City.: State: Zip:
Phone : Fax:  
Your Spouse:    
Name: Occupation: Employer's Name
Address:    
City.: State: Zip:
Phone : Fax:  

Step 5: Dental History

 
What is the reason for your visit today?  
Date of last dental visit? Last dental cleaning? Last full mouth X-rays?
What was done at your last dental visit?  
Previous dentist's name? Telephone:  
Address: State: Zip:
How often do you have dental examinations? How often do you brush your teeth? How often do you floss?
What other dental aids do you use? (Interplak, toothpick, etc)  
Do you have dental problems now?    
If yes, please describe:  
     
Are any of your teeth sensitive to: Do your gums bleed or hurt? Do you:
Hot or Cold? Have your parents experienced gum disease or tooth loss? Clench or grind your teeth while awake or asleep?
Sweets? Have you noticed any loose teeth or change in bite? Bite your lips or cheeks regularly?
Biting or Chewing? Does your food tend to become caught in between your teeth? Hold foreign objects with your teeth?
Have you noticed any mouth odors or bad tastes? If yes,where? Mouth breath while awake or asleep?
Do you frequently get cold sores, blisters, or any other oral lesions?   Have tired jaws, especially in the morning?
    Snore or have any other sleeping disorders?
    Smoke/chew tobacco or use other tobacco products?
     
Have you ever had: Have you experienced: Are you satisfied with your teeth's appearance?
Orthodontic treatment? Clicking or popping of the jaw? Would you like to keep all of your teeth all of your life?
Oral Surgery? Pain? (joint, ear, side of face): Do you feel nervous about having dental treatment?
Periodontal treatment? Difficulty in opening or closing the mouth? If so, what is your biggest concern?
Your teeth ground or the bite adjusted? Difficulty in chewing on either side of the mouth? Have you ever had an upsetting dental experience?
A bite plate or mouth guard? Headaches, neckaches, or shoulder aches? If yes, please describe  :
A serious injury to the mouth or head? Sore muscles (neck, shoulders)?  
If so, please describe, including cause:    
     
Is there anything else about having dental treatment that you would like us to know?  
If yes, please describe:  

Step 6: Medical History

 
Have you been under the care of a medical doctor during the past two years?
If yes for what?
Physician's name: Phone:  
Address: City: State:     Zip:
Have you taken any medication or drugs during the past two years?
Are you taking any medication or drugs currently, including regular doses of aspirin or over the counter herbal medicines?
If yes, please list name and dosage:
Have you ever taken any prescription drugs for weight loss, including Fen-Phen (fenfluramine-phentermine); Pondimen (fenfluramine); and Redux (dexfenfluramine)?
If yes to the above, did you have a medical exam for heart issues?
Are you aware of having an alergic (or adverse) reaction to any medication or substance?
If yes, please list:
Have you been a patient in the hospital during the past 5 years?  
     
Indicate which of the following you have had or have at present. Select "yes" or "no"
Heart (Surgery, Disease, Attack) Ulcers Hepatitis (A.B.C)
Chest Pain Diabetes Venereal Disease
Congenital Heart Disease Thyroid Problems A.I.D.S
Heart Murmur Glaucoma H.I.V Positive
High Blood Pressure Contact Lenses Cold Sores/Fever Blisters
Mitral Valve Prolapse Emphysema Blood Transfusion
Artificial Heart Valve Chronic Cough Hemophilia
Heart Pacemaker Tuberculosis Sickle Cell Disease
Rheumatic Fever Asthma Bruise Easily
Arthritis/Rhuematism Hay Fever Liver Disease
Cortisone Medicine Latex Sensitivity Yellow Jaundice
Swollen Ankles Allergies or Hives Neurological Disorders
Stroke Sinus Trouble Epilepsy or Seizures
Diet (Special/Restricted) Radiation Therapy Fainting or Dizzy Spells
Artificial Joints (hip,knee,etc) Chemotherapy Nervous/ Anxious
Kidney Trouble Tumors Psychiatric/ Psychological Care
     

Step 7: Authorization

 
Authorization to submit information goes here

 

I do hereby authorize this information to be sent