Patient Registration

About

Personal Information:

Gender: Male Female Won't Say
Marital Status: Married Single Won't Say
Title: Mr Ms Dr
Are You Available at Short Notice for Appointment:
Yes No
Best Way to Contact: Mobile Work Home Text Email
Best Day to Visit: Mon Tue Wed Thu Fri Sat Sun
Referral Information : Another Patient Friend Relative Co-worker Flyer Website Walkin Other

Insurance

Primary Insurance Details:

Relationship:
Self Spouse Other
Relationship:
Self Spouse Other

Medical

Medical History:

(All information is confidential)

The following information is required by the dentist to assist in proper diagnosis & treatment

1. Have you ever had a serious illness, requiring hospitalization in the past five years or extensive medical care Yes No

Please Specify

2. Do you use any prescription or non-prescription drugs regularly?
Yes No
3. Do you have any allergic conditions: e.g. hay fever, skin rash, food allergies, metal, latex Yes No
Do any allergic reactions result in headaches, shortness of breath, chest constrictions, nausea? Yes No
4. Have you ever experienced any unusual reaction to any of the following
Local Anesthesia (freezing) Aspirin Pencillin
Sulpha Drugs Barbiturates (Sleeping Pills) Any Other Medicine
5. Do you have any disease, condition of problem that you think the doctor should know about?
Cortisone/Steroid Therapy
Drug/Alcohol Dependency
Mental or Nervous disorder
Scarlet or Rheumatic Fever
Bruise easily or bleed abnormally
Organ Implants or Medical Implants
Stomach/Intestinal Problems/Ulcers
Heart Murmur or Mitral valve Prolapse
Kidney Problems
Joint Replacement
Epilepsy or Seizures
Hyper/Hypo Glycemia
Cancer/Chemotherapy
Arthritis or Rheumatism
Malignant Hyperthermiabr
High/low blood pressure
Fainted ever
Emphysema
Tuberculosis
Sinus Trouble
Liver Disease
Lung Disease
Hepatitis A/B/C
Thyroid Disease
Experience shortness of Breath or Chest Pain when walking or climbing stairs
Stroke
Herpes
Diabetes
Jaundice
AIDS/HIV
Glaucoma
Cold Scores
Heart Attack
Other
6. Have you had any injury, surgery or x-ray therapy to your face or jaws?
Yes No
1. Reason for Today's Visit
Exam Preventive Dental Emergency Other
2. How frequently do you visit your dentist?
3-6 months Annually Never
5. Do you have any of the following?

Check all that apply

Loose or Broken Teeth
Loose or Broken Fillings
Stores or Growth in the mouth
Jaw Pain/Migraine Headache
Bruise easily or bleed abnormally
Teeth Strain
Teeth feel rough
Grinding Teeth
Gum swollen/tender
Root Canal
Bleeding Gum
Bad Breath
Oral Surgery
Missing Teeth
Implant
Does your jaw crack or pop when opened widely
Other
5. Are your teeth sensitive to:
Hot Cold Biting Sweets
6. Do You Smoke?
Yes No
7. Have you ever experienced complications during dental treatment?
Yes No
8. Are you nervous about dental appointments?
Yes No

Confirm

I the undersigned, certify I have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information. I had the opportunity to ask questions and receive answers to any questions regarding medical-dental history and I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I also understand that consultation with my medical doctor, previous dentist and within our group may be required, and I consent to my physician being contacted as necessary. I understand that responsibility for payment for the dental services provided for myself and my dependants is mine, and I will assume responsibility for less associated with these services at the end of each visit.

Signed by Self Parent Guardian