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Download Dental Registration – PDF Form
Thank you for choosing our office. We will strive to provide you with the best possible dental care. To help us meet your entire dental healthcare needs, please fill out this form completely.
Patient’s Last Name
First
Middle
Preferred Name / Nickname
Birthdate
Social Security Number
MaleFemale
Mr.Ms.Dr.Mrs.
SingleMarriedWidowedSeparatedDivorced
Street Address
Home Phone
City
State
Zip
Cell Phone
Email Address
Occupation
Employer
Work Phone
How did you hear about our office? FamilyFriend/CoworkerInsurance DirectoryInternet/EmailFlyer/Direct MailingOutdoor SignsMarketing Representative
Whom may we thank for referring you to your practice?
Other Family Members Seen Here
Person Responsible for Bill
Relationship to Patient (self/spouse/child)
Card Type: AmexVisaMaster CardDiscoverCareCreditLending ClubOther Card Number:
Card Expiration Date
Subscriber’s Name:
Subscriber’s Social Security #:
Subscriber’s Email Address:
Subscriber’s DOB:
Subscriber’s Street Address (if different from patient’s)
Subscriber’s Cell Phone
Subscriber’s Work Phone
Primary Insurance Company
Subscriber’s ID #:
Group #:
Secondary Insurance Company
Reason for Today’s Visit: Routine Exam/CleaningPain/EmergencyConsultationOther
Please Describe:
Are you in pain? YesNo
If yes, how long?
Please indicate any of the following problems: Red, swollen or bleeding gumsLost/broken filling(s)Blisters/sores in or around the mouthBroken/chipped toothStained teethSensitive to coldBad breathSensitive to heatRinging in earSensitive teeth or gumsTeeth grindingDiscomfort, clicking or popping in jaw
Do you require pre-medication (antibiotics prior to dental treatment)? YesNoDon’t Know
Previous Dentist
City, State
Phone
Last Dental Visit
Last X-Rays
Reasons for changing dentist: MovedChanged insuranceNot satisfied with previous dentistReferred to our officeOther
Name of Primary Physician
Physician’s Phone
Please indicate if you have or ever had any of the following diseases or medical conditions: Heart Attack / StrokeStomach Problems / UlcersSevere/Frequent HeadachesHeart Surgery / PacemakerPsychiatric ProblemsFrequent Neck PainHeart MurmurVenereal DiseaseShinglesRheumatic FeverAlcohol / Drug AbuseAsthmaMitral Valve ProlapseTuberculosis (TB)Difficulty BreathingArtificial ValvesJaw Problems (TMJ / TMD)DiabetesHeart DiseaseCancer / TumorAnemiaCongenital Heart DefectChemotherapy / RadiationLow Blood PressureChest PainsHepatitisHigh Blood PressureScarlet FeverHIV+ / AIDSBleeding ProblemsKidney ProblemsArthritis / RheumatismGlaucomaLiver ProblemsArtificial Bones / JointsBack ProblemsRespiratory ProblemsEmphysemaSinus ProblemsFainting / Seizures / EpilepsyOther Medical Conditions
Please Describe Other Medical Conditions:
Please list all medications you are currently taking:
Are you allergic to any of the following? AspirinPenicillinLocal AnestheticsIbuprofenCodeineSulfa DrugsLatexOther Medications
Please list any Other Medications, patient is allergic to:
Do you use tobacco? YesNo
If yes, what form?
How much?
How long?
Are you pregnant? YesNo
Are you nursing? YesNo
Name of Local Friend or Relative (not living at same address)
Relationship to Patient
PATIENT/GUARDIAN SIGNATURE
DATE
Once your appointment is confirmed, please complete the Patient Screening Form.
