Patient Registration Form

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Email:

Preferred Name: *

Miss
Mr.
Mrs.
Ms.
Dr.

Referred by:

Name:

First

Middle

Last

SS#:

Sex: *

Employer:

Employment Status: *

Full Time
Part Time
Retired

Marital Status: *

Married
Single
Divorced
Separated
Widowed

Pref. Pharmacy:

College Student Status: *

Full Time
Part Time

School Name:

Emergency Contact:

Relationship:

Name of Insured:

Insured Soc. Sec.:

Employer:

ID#:

Relationship to Patient: *

Self
Spouse
Child
Other

Ins. Company:

Gr#:

Name of Insured:

Insured Soc. Sec.:

Employer:

ID#:

Relationship to Patient: *

Self
Spouse
Child
Other

Ins. Company:

Gr#: (

Do your gums bleed when you brush or floss? *

Are your teeth sensitive to cold, hot, sweets or pressure? *

Is your mouth dry? *

Have you had any periodontal (gum) treatments? *

Have you ever had orthodontic (braces) treatments? *

Have you had any problems associated with previous dental treatment? *

Is your home water supply fluoridated? *

Do you drink bottled or filtered water? *

If yes, how often? *

DAILY
WEEKLY
OCCASIONALLY

Are you currently experiencing dental pain or discomfort?. *

Do you have earaches or neck pains? *

Do you have any clicking, popping or discomfort in the jaw? *

Do you brux or grind your teeth? *

Do you have sores or ulcers in your mouth? *

Do you wear dentures or partials? *

Do you participate in active recreational activities? *

Have you ever had a serious injury to your head or mouth? *

What was done at that time?

What is the reason for your dental visit today?

How do you feel about your smile?

𝑱𝒐𝒊𝒏𝒕 𝑹𝒆𝒑𝒍𝒂𝒄𝒆𝒎𝒆𝒏𝒕. Have you had an orthopedic total joint replacement (hip, knee, elbow, finger)? *

Are you now under the care of a physician? *

Physician Name: *

Are you in good health? *

Has there been any change in your general health within the past year? *

If yes, what condition was treated? *

Do you wear contact lenses? *

Are you taking, or have you taken, any diet drugs such as Pondimin (fenfluramine), Redux (dexphenfluramine) or fen-phen (fenfluramine-phentermine combination)? *

Are you taking or scheduled to begin taking either of the medications alendrontate (Fosamax®) or risendronate (Actonel®) for osteoporosis or Paget’s disease?. . . . . . . . . . . . . . . . . . . . . . *

Since 2001, were you treated or are you presently scheduled to begin treatment with the intravenous bisphosphonates (Aredia® or Zometa®) for bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease, multiple myeloma or metastic cancer? *

Have you had a serious illness, operation or been hospitalized in the past 5 years? *

If yes, what was the illness or problem? *

Are you taking or have you recently taken any prescription or over the counter medicine(s)? *

If so, please list all, including vitamins, natural or herbal preparations and/ or diet supplements: *

Do you use controlled substances (drugs)? *

Do you use tobacco (smoking, snuff, chew, bidis)? *

If so, how interested are you in stopping? *

VERY
SOMEWHAT
NOT INTERESTED

Do you drink alcoholic beverages? *

If yes, how much alcohol did you drink in the last 24 hours? *

If yes, how much do you typically drink in a week? *

Pregnant? *

Number of weeks: *

Taking birth control pills or hormone replacement? *

Nursing? *

If yes, have you had any complications? *

Local anesthetics *

specify type of reaction *

Aspirin *

specify type of reaction *

Penicillin or other antibiotics *

specify type of reaction *

Barbituates, sedatives, or sleeping pills *

specify type of reaction *

Sulfa drugs *

specify type of reaction *

Codeine or other narcotics *

specify type of reaction *

Metals *

specify type of reaction *

Latex (rubber) *

specify type of reaction *

Iodine *

specify type of reaction *

Hay fever / seasonal *

specify type of reaction *

Animals *

specify type of reaction *

Food *

specify type of reaction *

Other *

specify type of reaction *

Heart murmur *

Mitral valve prolapse *

Artificial heart valves *

Rheumatic fever *

Cardiovascular disease *

Angina *

Arteriosclerosis *

Congestive heart failure *

Coronary artery disease *

Damaged heart valves *

Heart attack *

Low blood pressure *

High blood pressure *

Congenital heart defects *

Pacemaker *

Rheumatic heart disease *

Abnormal bleeding *

Anemia *

Blood transfusion *

Hemophilia *

AIDS or HIV infection *

Arthritis *

Autoimmune disease *

Rheumatoid arthritis *

Systemic lupus erythematosus *

Asthma *

Bronchitis *

Emphysema *

Sinus trouble *

Tuberculosis *

Chest pain upon exertion *

Chronic pain *

Diabetes Type I or II *

Eating disorder *

Malnutrition *

Gastrointestinal disease *

G.E. Reflux/Persistent heartburn *

Ulcers *

Thyroid problems *

Stroke *

Glaucoma *

Hepatitis, jaundice or liver disease *

Epilepsy *

Fainting spells or seizures *

Neurological disorders *

If yes, specify: *

Sleep disorder *

Mental health disorders *

If yes, specify: *

Recurrent infections *

Type of infection: *

Kidney problems *

Night sweats *

Osteoporosis *

Persistent swollen glands in neck *

Severe headaches/ Migraines *

Severe of rapid weight loss *

Sexually transmitted disease *

Excessive urination *

Cancer/Chemotherapy/ Radiation treatment *

Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment? *

Do you have any disease, condition, or problem not listed above that you think I should know about? *

Name of physician or dentist making recommendation: *

Please explain: *

To keep our fees to you as low as possible, we ask that payment be made at the time of service. For your convenience an estimate for services will be prepared in advance of your appointmenus to ensure you opportunity to plan for your dental care. We believe whether you privately pay or have dental insurance to assist you, everyone deserves the care they need and want.

We are happy to file your dental claims to assist you in receiving the full benefits of your coverage. We request you familiarize yourself with your insurance benefits, and provide us the conect information to assist you with the submittal of claims. We will accept the estimated insurance payment directly from your insurance company provided payment is received from them within 45_60 days. Please realize that your insurance is a contract between you, your employer, and the insurance company: therefore, we cannot guarantee coverage and your assistance may be requested. Not all services are covered benefits in all contracts; therefore, you are ultimately responsible for the total amount of your dental fees. The treatment recommended for you is indicated regardless of your dental insurance benefits, deduclibles, limitalions, or maximums

For your convenience we provide a variety of payment options to help you receive the quality care you need to enioy a healthy and confident smile. Please identify which form of payment is most convenient for you at the time of service.Cash/CheckCash/CheckMasterCardVisaOtherExtended Payment

lf applicable balances owing from a prior visit where insurance is not pending, or an insurance payment has not been received within 90-days, or the account has been sent to colleclions is considered past due. Payment of any past due balance is required to be paid in full before incuning new charges. Balances over 90-days may be subject to a rebilling fee

lf you are unable to keep an appointment that has been reserved for you we request you provide us with a 48-hour advance courtesy notice. Early notifcation ensures that we can offer you a more convenient appointment and allows us sufficient time to accommodate the needs of another patient. We realize that emergencies do occur and we will be floxible under those circumstances. Please be advised that a cancellation fee of $50.00 to $100.00 may be incurred depending upon length of appointment when suffcient notice is not provided as requested.

We ask that cell phones and pagers be turned off at all times while in the treatment area. lf being available for an emergency during your reserved appointment is necessary, please leave our office telephone number so you can be reached. Should an unfortunate emergency arise we would be happy to notify you in the treatment area immediately.

To ensure your records are current please notify us of any changes related to medical history, telephone number/s, address, employer or insurance information as they occur