Download Dental Registration – PDF Form

    Spyridon J. Condos, DDS LLC

    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 INFORMATION







    MaleFemale
    Mr.Ms.Dr.Mrs.
    SingleMarriedWidowedSeparatedDivorced











    FamilyFriend/CoworkerInsurance DirectoryInternet/EmailFlyer/Direct MailingOutdoor SignsMarketing Representative


    INSURANCE (PLEASE GIVE YOUR INSURANCE CARD TO THE RECEPTIONIST)



    Card Type: AmexVisaMaster CardDiscoverCareCreditLending ClubOther
    Card Number:

















    DENTAL HISTORY


    Routine Exam/CleaningPain/EmergencyConsultationOther



    YesNo



    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


    YesNoDon’t Know







    MovedChanged insuranceNot satisfied with previous dentistReferred to our officeOther


    MEDICAL HISTORY




    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




    AspirinPenicillinLocal AnestheticsIbuprofenCodeineSulfa DrugsLatexOther Medications



    YesNo




    For Women:

    YesNo


    YesNo

    IN CASE OF EMERGENCY