Register Online Now Don’t Hesitate to contact me for any kind of information Welcome Thank you for selecting our dental healthcare team! We will strive to provide you with the best possible dental care. To help us meet all your dental healthcare needs, please fill out this form completely in ink.If you have any questions or need assistance, please ask us - we will be happy to help. Patient# SS#/SIN Date Patient Information (Confidential) Name Birthdate Home Phone Address City State/Prov. Zip Email Cell Phone Check Appropriate BoxMinorSingleMarriedDivorcedWidowedSeparated If Student, Name of School/College City State Full TimePart Time Patient or Parent/Guardian's Employer Work Phone Address City State/Prov. Zip Spouse or Parent/Guardian's Name Employer Work Phone Whom may we thank for referring you? Person to contact in case of emergency Phone Responsible Party Name of Person Responsible for this Account Relationship to Patient Address Home Phone Email Cell Phone Driver's License # Birthdate Financial Institution Employer Work Phone SS#/SIN Is this person currently a patient in our officeYesNo For your convenience, we offer the following methods of payment. Please check the option you prefer. Payment in full at each appointment. CashPersonal CheckCredit CardVISAMaster CardI wish to discuss the office's payment policy. Insurance Information Name of Insured Relationship to patient Birthdate SS#/SIN Date Employed Name of Employer Union or Local# Work Phone Address of Employer City State/Prov. Zip Insurance Company Group # Policy/ID # Ins. Co. Address City State/Prov. Zip How much is your deductible? How much have you used? Max Annual Benifit Do you have any additional information?YesNo If yes complete the following Name of Insured Relationship to patient Birthdate SS#/SIN Date Employed Name of Employer Union or Local# Work Phone Address of Employer City State/Prov. Zip Insurance Company Group# Policy/ID# Ins. Co. Address City State/Prov. Zip How much is you deductible? How much have you used? Max annual benifit Patient Medical History Physician Office Phone Date of Last Exam 1. Are you under medical treatment now.....YesNo 2. Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years?.....YesNo If yes, please explain 3. Are you taking any medication(s) including non-prescription medicine?.....YesNo If yes, what medication(s) are you taking 4. Have you ever taken Fen-Phen/Redux?.....YesNo 5. Have you ever taken Fosamax, Boniva, Actonel or any cancer medications conatining bisphosphonates?.....YesNo 6. Have you taken Viagra, Revatio, Cialis or Levitra in last 24 hours?.....YesNo 7. Do you use tobacco?.....YesNo 8. Do you use controlled substances?.....YesNo 9. Are you wearing contact lenses.....YesNo 10. Are you allergic to or have you had any reactions to the following? Local Anesthetics (e.g. Novocain).....YesNo Penicillin or any other Antibiotics.....YesNo Sulfa Drugs.....YesNo Barbiturates.....YesNo Sedatives.....YesNo Iodine.....YesNo Aspirin.....YesNo Any Metals (e.g. nickel, mercury, etc.).....YesNo Latex Rubber.....YesNo Other (please list)..... 11. Do you have a persistent cough or throat clearing not associated with a known illness (lasting more than 3 weeks)?.....YesNo 12. Women Only : a) Are you pregnant or think you may be pregnant?...YesNo b) Are you nursing?....YesNo c) Are you taking oral contrceptives?.....YesNo 13. Do you have or have you had any of the following? High Blood Pressure.....YesNo Heart Attack.....YesNo Rheumatic Fever.....YesNo Swollen Ankles.....YesNo Fainting/Seizures.....YesNo Asthma.....YesNo Low Blood Pressure.....YesNo Epilepsy/Convulsions.....YesNo Leukemia.....YesNo Diabetes.....YesNo Kidney Diseases.....YesNo AIDS or HIV Infection.....YesNo Thyroid Problem.....YesNo Heart Disease.....YesNo Cardiac Pacemaker.....YesNo Heart Murmur.....YesNo Angina.....YesNo Frequently Tired.....YesNo Anemia.....YesNo Emphysema.....YesNo Cancer.....YesNo Arthritis.....YesNo Joint Replacement or Implant.....YesNo Hepatitis/Jaundice.....YesNo Sexually Transmitted Disease.....YesNo Stomach Troubles/Ulcers.....YesNo Chest Pain.....YesNo Easily Winded.....YesNo Stroke.....YesNo Hay Fever/Allergies.....YesNo Tuberculosis.....YesNo Radiation Therapy.....YesNo Glaucoma.....YesNo Recent Weight Loss.....YesNo Liver Disease.....YesNo Heart Trouble.....YesNo Respiratory Problems.....YesNo Mitral Valve Prolapse...YesNo Other... Patient Dental History Name of Previous Dentist and Location Date of Last Exam 1. Do you gums bleed while brushing or flossing?.....YesNo 2. Are your teeth sensitive to hot or cold liquids/foods?.....YesNo 3. Are your teeth sensitive to sweet or sour liquids/foods?.....YesNo 4. Do you feel pain to any of your teeth?.....YesNo 5. Do you have any sores or lumps in or near your mouth?.....YesNo 6. Have you had any head, neck or jaw injuries?.....YesNo 7. Have you ever experienced any of the following problems in your jaw? Clicking.....YesNo Pain(joint, ear, side of face)......YesNo Difficulty in opening or closing.....YesNo Difficulty in chewing.....YesNo 8. Do you have frequent headaches?.....YesNo 9. Do you clench or grind your teeth?.....YesNo 10. Do you bite you lips or cheeks frequently?.....YesNo 11. Have you ever had any difficult extractions in the past.....YesNo 12. Have you ever had any prolonged bleeding following extractions?.....YesNo 13. Have you had any orthodontic treatment?.....YesNo 14. Do you wear dentures or partials?.....YesNo If yes, date of placement 15. Have you ever received oral hygiene instructions regarding the care of your teeth and gums.....YesNo 16. Do you like your smile?.....YesNo Authorization and Release I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such Dental care to third party pavors and/or health practitioners. authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise pavable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. Signature of patient (or parent/guardian if minor) Date Doctor's Comment Signature Date
