Patient Registration Form Patient Information *All fields requiredFirst Name* Last Name* Date of Birth* MM slash DD slash YYYY Registering for a child?* Yes No Parent/Guardian Name* HiddenOther parental consent required* Yes No HiddenMother’s name* HiddenBusiness Tel*HiddenFather’s name* HiddenBusiness Tel*Contact InformationEmail* Phone*In case of emergency, please notify:HiddenName* HiddenRelation* HiddenPhone*Contact OptionsHiddenI prefer appointment reminders by* Phone SMS (TEXT) Email HiddenWhom may we thank for referring you?* HiddenAre any other members of your family patients at our practice?* Yes No HiddenPlease list all family members*Insurance Information Yes, insurance applies to me No, insurance does not apply to me Please complete the following if you have dental insuranceHiddenName of insured/subscriber* HiddenDate of Birth* MM slash DD slash YYYY HiddenPatient's relationship to subscriber* Self Spouse Child HiddenPlace of Employment* Insurance Company Member ID Policy Number HiddenCertificate/ID #* HiddenI authorize release to my dental benefits plan administrator information contained in claims and/or predeterminations* Yes Medical History The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by Doctor/Patient confidentiality. The Dentist will review the questions and explain any that you do not understand. Please complete the entire form.HiddenAre you being treated for any medical condition at the present or any time within the past year?* Yes No Not Sure/Maybe HiddenWhen was your last medical checkup?* MM slash DD slash YYYY HiddenHas there been any change in your general health in the past year?* Yes No Not Sure/Maybe HiddenPlease Specify*HiddenAre you taking any prescription, non-prescription medications, or herbal supplements?* Yes No Not Sure/Maybe HiddenPlease list and provide dosages. If there is insufficient room, please bring a written list of all your medications to your first appointment.HiddenDo you have any allergies?* Yes No Not Sure/Maybe Hidden--select--*MedicationsLatex/Rubber ProductsOther (e.g hayfever, foods, etc)HiddenHave you ever had a peculiar or adverse reaction to any medicines or injections?* Yes No Not Sure/Maybe HiddenPlease list below with approximate dates* MM slash DD slash YYYY HiddenDo you have or have you ever had asthma?* Yes No Not Sure/Maybe HiddenDo you have or have you ever had any heart or blood pressure problems?* Yes No Not Sure/Maybe HiddenDo you have or have you ever had an artificial heart valve, infection of the heart (i.e. #infective endocarditis), a heart condition from birth (i.e. congenital heart disease), or a heart transplant?* Yes No Not Sure/Maybe HiddenDo you have a prosthetic or artificial joint?* Yes No Not Sure/Maybe HiddenDo you have any conditions which may affect your immune system (i.e. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?* Yes No Not Sure/Maybe HiddenPlease specify*HiddenHave you ever had hepatitis, jaundice, or liver disease?* Yes No Not Sure/Maybe HiddenDo you have a bleeding problem or bleeding disorder?* Yes No Not Sure/Maybe HiddenPlease specify*HiddenHave you ever been hospitalized for any illnesses or operations?* Yes No Not Sure/Maybe HiddenPlease specify*HiddenDo you have, or have ever had any of the following? Please check* Select All Chest pain/angina Osteoporosis Medications Mitral Valve Prolapse Shortness of Breath Rheumatic Fever Heart Attack Stroke Cancer Pacemaker Lung Disease Heart Murmur Arthritis Steroid Therapy Diabetes Tuberculosis Drug/Alcohol Dependency Seizures Thyroid Disease Stomach Ulcers Kidney Disease None of the above HiddenAre there any conditions/diseases not listed that you have or have had?* Yes No Not Sure/Maybe HiddenIf yes, please specify:*HiddenAre there any diseases/medical problems that run in your family (e.g. diabetes, cancer, heart disease, etc.)?* Yes No Not Sure/Maybe HiddenIf yes, please specify:*HiddenDo you smoke or chew tobacco products?* Yes No Not Sure/Maybe HiddenAre you nervous during dental treatment?* Yes No Not Sure/Maybe HiddenFor women only: Are you pregnant or breastfeeding?* Yes No Not Sure/Maybe HiddenWhat is your expected delivery date?* MM slash DD slash YYYY Dental HistoryHiddenDo you have any specific dental concerns? Please list:*HiddenWhen was your last dental appointment?* MM slash DD slash YYYY HiddenHow often do you see the dentist?* Not Applicable Every 3 months Every 4 months Every 6 months Only when something is bothering me HiddenIs there anything about the appearance of your teeth that you would like to change?*HiddenHave you ever whitened (bleached) your teeth? Yes No Not Sure/Maybe HiddenDo you feel uncomfortable or self-conscious about the appearance of your teeth?* HiddenHave you been disappointed with the appearance of previous dental work? I agree to receive emails with related information and updates. NameThis field is for validation purposes and should be left unchanged.