Patient Registration

New patients: call to schedule your appointment first!

• required Personal Information
• First Name:			• Last Name:
• Address:			• City:
• State/Zip:			• Work Phone:
• Home Phone:			Other Phone:
• Email:			• Date of Birth:
Spouse/Partner:			Employer:
Insured's Name:			Relationship:
Insurance Company:			Plan Name:
			Group #:
2nd Insurance:			Plan Name:
			Group #:
Emergency Contact:			Phone Number:
Dentist Name:			Referral Source:
Dental History
What is the reason for your visit? (Provide as much information as possible)			When was your last full mouth x-rays series taken? When was your last cleaning?
Please check all that apply:
I do not brush regularly      I do not floss regularly      My gums bleed      My teeth are sensitive to hot/cold      I have discomfort or clicking in my jaw joint      I do not use powered toothbrush (Sonicare)      When I eat, food catches between my teeth      I do not like my smile
Medical History
Please check all that apply:
I am currently under physician’s care      I have been hospitalized or had a major operation      I am not in good health      I bruise easily      I smoke      I take medications      I am allergic to Latex      I am pregnant or nursing      I am trying to get pregnant
Physician Name:			Phone Number:
Hospitalization details:			I am allergic to following medications:
Do you have, or have you had any of the following?
Heart Disease Diabetes Stroke Heart Murmur Epilepsy Kidney Disease Rheumatic Fever Arthritis Pace Maker High Blood Pressure Low Blood Pressure Blood Disease Recent Blood Transfusion Asthma			Cortisone Medicine Tuberculosis Stomach/Intestinal Disease Ulcer AIDS/HIV + Radiation Treatment Tumor History Chemotherapy Liver Disease Drug/Alcohol Addiction Venereal Disease Psychiatric Care Thyroid Disease
Other Comments/Questions:
Please indicate your appointment availability
• I would like to schedule: Free 20 Minute Dental Implant Consultation (Please bring your x-rays) Comprehensive 1 Hour Examination