New Patient Registration Step 1 of 3 0% New Patient Registration Form Personal InformationPatient’s Name(Required) First Middle Last Marital statusSingleMarriedOthersDate of Birth(Required) MM slash DD slash YYYY How do you want to be addressed?MaleFemaleNo preferenceParent/Guardian (for minor patient)FatherMotherGuardianAddressSuite#StreetCityPostal CodeEmailPhoneHomeBusinessCell(Required)Emergency Contact InformationNameOther family member in this office?RelationWhom may we thank for this referral?PhoneWho responsible for this account?Dental Insurance InformationDo you have any dental coverage?(If yes please provide to the office)Do you have second coverage thru another family member?(If yes please provide to the office) Medical History Form Patient’s Name(Required) Patient's Name Medical Doctor's Name Phone or Address Please check the appropriate answers1 - Are you under the care of physicians?(Required) Yes No If YES, Since when MM slash DD slash YYYY Why2 - Have you been hospitalized for any illness or operations?(Required) Yes No If YES, when MM slash DD slash YYYY Why3 - Are you taking any medications or substances?(Required) Yes No If YES, please list them(Required)4 - Have you ever been advised to take antibiotics before dental appointments?(Required) Yes No If YES, Why?5 - Do you currently take blood thinners (Warfarin, Aspirin or Others)?(Required) Yes No If YES, please list them6 - Have you ever bled excessively after being cut or injured?(Required) Yes No 7 - Do you have any Allergy or Unusual Reaction to Penicillin, antibiotics or Anesthetics?(Required) Yes No 8 - Do you have or have you ever had any of the following? Chest Pain Chest Pain Heart Attack Heart Attack Stroke Stroke High Blood Pressure High Blood Pressure Heart Valve Problem Heart Valve Problem Low Blood Pressure Low Blood Pressure Diabetes Diabetes Asthma Asthma Bronchitis / Emphysema Bronchitis / Emphysema Allergy to Medications, Food or Substances Allergy to Medications, Food or Substances Hepatitis Hepatitis Tuberculosis Tuberculosis Rheumatic Fever Rheumatic Fever Aids / HIV Aids / HIV Stomach Problems Stomach Problems Liver Problems Liver Problems Kidney Problems Kidney Problems Depression Depression Epilepsy / Seizure Epilepsy / Seizure Radiation / Chemo Treatment Radiation / Chemo Treatment Blood Disorder Anaemia/Leukaemia Blood Disorder Anaemia/Leukaemia Venereal Disease Venereal Disease Joint Replacement Joint Replacement Smoking Smoking 9 - For WOMEN, Are you pregnant or suspect you may be? Yes No If YES, what is the expected delivery date? MM slash DD slash YYYY 10 - Are there any conditions or disease not listed above that you have or have had? Yes No If YES, please list them11 - Is there anything else we should know about your health that we have not covered in this form? Dental History Form Patient's Name:(Required)1 - Purpose of Visit, (What condition concern you at present)? Please check the answers.Regular Check Up Regular Check Up Tooth Decay / Cavities Tooth Decay / Cavities Unattractive Smile Cosmetic Dentistry Unattractive Smile Cosmetic Dentistry Missing Teeth Missing Teeth Crooked Teeth Orthodontic Treatment Crooked Teeth Orthodontic Treatment Food Trap between Teeth Food Trap between Teeth Mouth Sore Mouth Sore Cleaning Cleaning Chipped / Broken / Cracked Tooth Chipped / Broken / Cracked Tooth Stained Teeth / Whitening Stained Teeth / Whitening Wisdom Tooth Impacted Teeth Wisdom Tooth Impacted Teeth Invisalign Invisalign Muscles Pain or Soreness Muscles Pain or Soreness Toothaches Tooth Sensitivity Toothaches Tooth Sensitivity Gums Bleeding / Disease Gums Bleeding / Disease Grinding / Clenching Grinding / Clenching Botox Botox Jaw Clicking Jaw Clicking Other Other 2 - Your last dental visit? MM slash DD slash YYYY Pervious Dentist:Phone:Did you have cleaning then? Yes No 3 - Do you brush daily? Yes No Do you floss daily? Yes No 4 - Do you have Oral Habits? (Grinding, Clenching or Other) Yes No 5 - Do you have or have you ever had any of the following? Gum Treatments/Surgery Gum Treatments/Surgery Bridge Bridge Night Guard Night Guard Jaw Surgery Jaw Surgery Root Canal Root Canal Crown / Veneer Crown / Veneer Orthodontic Treatment Orthodontic Treatment Orthodontic Treatment Orthodontic Treatment 6 - Are there any conditions or problems not listed above that you have or have had?(If YES, please explain) Yes No 7 - Have you ever had any problems or complications with previous dental treatment?(If YES, please explain) Yes No 8 - Are you unhappy with the appearance of your teeth? Would you like a smile brighter?(If YES, please explain) Yes No 9 - Is there anything else we should know about your teeth that we have not covered in this form?(If YES, please explain) Yes No Consent to ReleaseI authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I authorize release of any information concerning my (or my child's) health care, advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits. I authorize release of any information concerning my (or my child's) health care, advice and treatment to another dentist. I hereby authorize payment of insurance benefits directly to the dentist or dental group, otherwise payable to me. I understand that my dental insurance carrier or payor of my dental benefits may pay less than the actual bill for services. I understand I am financially responsible for payment of services not paid, in whole or in part by my dental care payor. I attest to the accuracy of the information on this page and my medical and dental history.Date(Required) MM slash DD slash YYYY Patient's or Guardian's signature(Required)
