New Patient Registration Form

If you are looking for a great dental experience, fill out the form below to instantly submit your new patient information to us. We welcome you!

Personal Information

First:

Last:

MI:

Birthday:

SS#:

Email Address:

Home Phone:

Cell Phone:

Preferred Contact Method:

Home Phone
Cell Phone

Gender:

Male Female
Prefer not to answer

Status:

Single Married
Divorced Widowed

Address and Phone

Home Address:

City:

State:

Zip:

Does your whole family live at this address?

Yes No

Emergency Contact

Emergency Contact Name:

Emergency Contact Phone:

Relationship:



Subscribers Name:

Subscriber ID#:

Relationship to Subscriber:

Insurance Company Name:

Insurance Phone Number:

Employer Name:

Group Name:

Group #:


(If you have a second insurance) Fill Out The Following Insurance Information

Subscriber Name:

Subscriber ID#:

Relationship to Subscriber:

Insurance Company Name:

Insurance Phone Number:

Employer:

Group Name:

Group #:


Insurance Comments:


Medical History

Medical Doctor's Information

Name:

City:

State:


List all medications that you are now taking:


Are you allergic to any of the following?

Anesthetic

Yes No

Aspirin

Yes No

Codeine

Yes No

Ibuprofen

Yes No

Iodine

Yes No

Latex

Yes No

Penicillin

Yes No

Sulfa

Yes No

Other:


Do you have any of the following medical conditions?

Asthma

Yes No

Bleeding Problems

Yes No

Cancer

Yes No

Diabetes

Yes No

Heart Murmur

Yes No

Heart Trouble

Yes No

High Blood Pressure

Yes No

Joint Replacement

Yes No

Kidney Disease

Yes No

Liver Disease

Yes No

Psychiatric Treatment

Yes No

Sinus Trouble

Yes No

Stroke

Yes No

Ulcers

Yes No

Rheumatic Fever

Yes No

Other

What kind and how:


I don't use tobacco

Full or Part Time?

Full-Time Part-Time
Not a Student

Reason for your visit:

Date of last cleaning and exam:


Previous Dentist's Information

Name:

City:

State:


Are You Pregnant?

Yes
No

Unusual reaction to dental injections?

Yes
No

Are you in pain?

Yes
No

Do you have a Panoramic x-ray or Full Mouth x-rays that are less than 5 years old?

Yes
No

Do you have BiteWing x-rays that are less than 1 year old?

Yes
No

I authorize this office to release information regarding my treatment to my dental insurance carriers. All insurance benefits are assigned to this office. I accept full responsibility for all charges related to my dental care.

How did you hear about us? If it was from a friend, please let us know so we can thank them!


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