New Patient Registration Form

General Information

Name *

First

Last

Date of Birth *//

Age

Gender *

Male
Female

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Billing Address (If Different)

Address Line 1

Address Line 2

City

State

Zip Code

Contact Information

Cellular Phone

Home Phone

Work Phone

Email Address *

Referred To Us By

Preferred Contact Method: *

Preferred Billing Statement Method: *

Insurance Information

Primary Insured Name

Primary Member's Date of Birth

Primary Dental Insurance

Primary Insurance Member ID

Group Name (Employer)

Group Number

Secondary Insured Name

Secondary Member's Date of Birth

Secondary Dental Insurance

Secondary Insurance Member ID

Secondary Group Name (Employer)

Secondary Group Number

Healthcare Provider Information

Name of Your Medical Doctor

Medical Doctor Phone Number

Date of Last Visit

Name of Previous Dentist

Date of Last Visit

Dental Health History

Are you apprehensive about dental treatment

Have you had problems with previous dental treatment?

Do you gag easily?

Do you wear dentures?

Does food catch between your teeth?

Do you have difficulty chewing your food?

Do you chew on only one side of your mouth?

Do you chew on only one side of your mouth because of pain?

Do your gums bleed easily?

Do your gums feel swollen or tender?

Have you ever noticed slow-healing sores in or about your mouth?

Are your teeth sensitive?

Do you feel twinges of pain when your teeth come in contact with hot foods or liquids?

Cold foods or liquids?

Sours?

Sweets?

Do you take fluoride supplements?

Are you dissatisfied with the appearance of your teeth?

Do you prefer to save your teeth?

Do you want complete dental care?

How often do you brush?

How often do you floss?

Does your jaw make noise so that it bothers you or others?

Do you clench or grind your jaws frequently?

Do your jaws ever feel tired?

Does your jaw get stuck so that you can't open or close freely?

Does it hurt when you chew or open wide to take a bite?

Do you have earaches or pain in front of the ears?

Do you have any jaw symptoms or headaches upon awaking in the morning?

Does jaw pain or discomfort affect your appetite, sleep, daily routine, or other activities?

Do you find jaw pain or discomfort extremely frustrating or depressing?

Do you take medications or pills for pain or discomfort (pain relievers, muscle relaxants, antidepressants)?

Do you have a temporomandibular (jaw) disorder (TMD)?

Do you have pain in the face, cheeks, jaws, joints, throat, or temples?

Are you unable to open your mouth as far as you want?

Are you aware of an uncomfortable bite?

Have you had a blow to the jaw (trauma)?

Are you a habitual gum chewer or pipe smoker?

Do you snore?

Are you excessively tired during the day?

Have you been told you stop breathing during sleep?

Is your neck size greater than 17 inches (male) or 16 inches (female)?

Medical Health History

Heart problems:

Chest pain

shortness of breath

Blood pressure problem

Heart murmur

Heart valve problem

Taking heart medication

Rheumatic fever

Pacemaker

Artificial heart valve

Blood problems:

Easy bruising

Frequent nosebleeds

Abnormal bleeding

Blood disease (anemia)

Ever require a blood transfusion?

Allergy Problems:

Hay fever

Sinus problems

Skin rashes

Taking allergy medication

Asthma

Intestinal Problems:

Ulcers

Weight gain or loss

Special diet

Constipation/Diarrhea

Kidney or bladder problems

Bone or Joint Problems:

Arthritis

Back or neck pain

Joint replacement (e.g. total hip, pins, or implants)

Are you taking or have you taken Bisphosphonate (e.g., Fosamax, Boniva, Actonel, Atelvia, Reclast, etc.)

Fainting Spells, Seizures or Epilepsy

Stroke(s)

Frequent or severe headaches

Thyroid problems

Persistent cough or swollen glands

Premedications required by physician

Cancer/tumor

Diabetes

Urinate more than 6 times a day

Thirsty or mouth is dry much of the time

Family history of diabetes

Tuberculosis or other respiratory disease

Do you drink alcohol?

If so, how much?

Do you smoke?

If so, please describe

Hepatitis, jaundice, or liver trouble

Herpes or other STD

HIV-positive / AIDS

Glaucoma

Do you wear contact lenses?

History of head injury?

Epilepsy or other neurological disease?

History of alcohol or drug abuse?

Do you have any disease, condition, or problem not listed previously that you feel we should now about?

If so, please describe

Please list any recent surgeries and dates:

Are you allergic, or have you reacted adversely to any of the following?

Aspirin

Codeine

Dental Anesthetics

Erythromycin

Jewelry

Latex

Metals

Penicillin

Tetracycline

Sulfa

Other

During the past 12 months, have you taken any of the following?

Antibiotics or sulfa drugs

Anticoagulants (e.g., Coumadin)

High blood pressure medicine

Tranquilizers

Insulin, Orinase, or similar drug

Aspirin

Digitalis or drugs for heart trouble

Nitroglycerin

Cortisone (steroids)

Natural remedies

Nonprescription drug/supplements

Other

Please list any medications you are currently taking:

For Women:

Are you taking birth control pills or other hormones?

Are you pregnant?

If yes, number of weeks:

Are you nursing?

Have you reached menopause?

If so, do you have any symptoms?

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