New Patient Registration

First Name *

Last Name *

Address

City

US States

Zip

Cell/Home Phone *

Work Phone

Date of Birth

Email

Create a Password For Your Patient Records *

If Patient Attends School Please Tell Us Where They Go? (copy)

Address

City

US States

Zip

Whom May We Thank For Referring You? *

Checkbox List

Full Name Of Responsible Party For This Account

Relationship To Patient

Address

City

US States

Zip

Cell/Home Phone

Work Phone

Date of Birth

Social Security Number

Employer

Employer Address

City

US States

Zip

Name of Insured

Date of Birth of Insured

Insurance Company

Insurance Address

City

US States

Zip

Phone

Member ID

Group Name

Group Number

Secondary Insurance Name

Name of Insured

Date of Birth

Insurance Company

Insurance Address

City

Member ID

US States

Group Name

Zip

Group Number

Are You Under The Care Of A Physician?

Yes
No

If Yes, Physician Name

Physician Phone Number

Date Of Last Physical Exam

Have You Been Hospitalized In The Last 5 Years?

Yes
No

Are You Taking Any Medications? Including Over The Counter *

Yes
No

Please List All Medications

Do You Use Tobacco?

Yes
No

Do You Drink Alcohol?

Yes
No

Do You Use Cocaine or Other Drugs?

Yes
No

Do You Wear Contacts?

Yes
No

Do You Have Any Known Drug Allergies?

Yes
No

If Yes, Please List Allergies

Have You Ever Had A Reaction To An Anesthetic?

Yes
No

Do You Have A Prosthetic Device, Pace Maker Or Artificial Joints?

Yes
No

If So, Please Explain

Please Check If You Have The Following

For Women Only:

Pregnant
Nursing
Taking Birth Control

Other:

Do Your Gums Bleed While Brushing?

Yes
No

Are Your Teeth Sensitive To Hot or Cold?

Yes
No

Are Your Teeth Sensitive To Sweet Or Sour Liquids/Foods?

Yes
No

Do You Feel Pain In Any Of Your Teeth?

Yes
No

Do You Have Any Sores Or Lumps In Your Mouth?

Yes
No

Have You Ever Suffered Trauma To Your Face Mouth Or Jaw?

Yes
No

Does Your Jaw Ever Click, Pop, Crackle Or Ache?

Yes
No

Do You Have Pain In Your Jaw Joint, Ear Or Side Of The Face?

Yes
No

Do You Have Difficulty Opening Or Closing Your Mouth?

Yes
No

Do You Have Difficulty Chewing?

Yes
No

Do You Have Frequent Headaches?

Yes
No

Do You Clench Or Grind Your Teeth?

Yes
No

Do You Bite Your Lips Or Cheeks Frequently?

Yes
No

Have You Had Problems With Previous Dental Work?

Yes
No

Have You Ever Had Braces?

Yes
No

How Many Times A Day Do You Brush Your Teeth?

Once
Twice

How Often Do You Floss?

Daily
Weekly
Not At All

Do You Use A Manual Brush Or Electric?

Electric
Manual

Do You Use Any Type Of Mouth Rinse?

Yes
No

Goals For Your Mouth, Teeth And Smile:

If You Could Change Anything About Your Smile, What Would That Be?

Single Checkbox Field

I certify that I have read and understand the above information. To the best of my knowledge, the above questions have been answered accurately. I understand that providing false or incorrect information can be dangerous to my health.

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