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Patient Registration
Get the busywork out of the way by filling out the patient registration form below. It only takes 5 minutes from the convenience of your home or office so that as soon as you arrive, you can begin enjoying our services.
   
Patient Information  
 
Date of Applicaton
2009
 
   
  LAST NAME
     
  Date of Birth
     
  SEX
     
  Social Security Number example: 111-22-3333
     
  Phone Number  
 
HOME
 example: (000)000-0000
 
WORK
 example: (000)000-0000
 
CELLPHONE
 example: (000)000-0000
     
 
Address
  
 
STREET
 
CITY
 
STATE
 
ZIP
     
  Responsible Party
 
PARENT
 
Names of Family Members
     
 
HOBBIES
     
  Who may we thank for referring you to us?
     
Health History  
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.
     
 
MEDICAL DOCTOR
 
Medical Doctor Phone
 example: (000)000-0000
     
  Are you allergic to any of the following?
(Check all that apply)








  Other, please explain:
     
  Do you have, or have you had, any of the following?
(Check all that apply)













  Have you ever had any serious illness not listed above? If yes, please explain.
     
  Are you under a physician's care now? If yes, please explain.
     
  Have you ever been hospitalized or had a major operation? If yes, please explain.
     
  Have you ever had a serious head or neck injury? If yes, please explain.
     
  Are you taking any medications, pills or drugs? If yes, please explain.
     
  Do you use tobacco?
     
  Do you use controlled substances? If yes, please explain.
     
  Have you ever taken Fosamax, Zoneta, Aredia, Actonel, or Boniva?
     
 
WOMEN:

Are you pregnant/trying to get pregnant?

Nursing?

Taking oral contraceptives?

     
  When was your last dental visit and what was it for?
(Check all that apply) 		Year
     
  Are you having pain or discomfort now?
     
  Why did you decide to make this appointment when you did?
     
  If anything were possible, what could we do to make your dental visit easier for you?
     
  If you could change anything about your teeth or smile, what would it be?
     
  Do you like the way your teeth look?
     
  Do you have special interests in any particular thing (such as implants. orthodontics, bleaching, bonding, etc.)?
     
  Do you get nervous about dental appointments?
     
Insurance Information
  Name of Subscriber/Policy Holder
     
  Employer
     
  Relationship to Patient
     
  Social Security Number example: 111-22-3333
     
  Date of Birth
     
  Dental Insurance Company
     
  Dental Insurance Co. Phone example: (000)000-0000
     
  Dental Insurance Co. Address  
 
STREET
 
CITY
 
STATE
 
ZIP
     
  Dental Insurance Group#
     
 
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