Step 1 of 6 - Patient Information

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This field is for validation purposes and should be left unchanged.

Patient Information

Date(Required)

MM slash DD slash YYYY

SS/HIC/Patient ID #

Last Name(Required)

First Name(Required)

Middle Initial

Address(Required)

E-mail(Required)

City(Required)

State(Required)

Zip(Required)

Sex(Required)

Age(Required)

Birthdate(Required)

MM slash DD slash YYYY

Marital Status(Required)

Married

Widowed

Single

Minor

Separated

Divorced

Partnered

Partnered for how many years?(Required)

Patient Employer/School

Occupation

Employer/School Address

Employer/School Phone

Spouse's Name

Spouse's Birthdate

MM slash DD slash YYYY

Spouse's SS#

Spouse's Employer

Whom may we thank for referring you?

Dental Insurance

Who is responsible for this account?(Required)

Relationship to Patient(Required)

Insurance Co.

Group #

Is patient covered by additional insurance?(Required)

Yes

Subscriber's Name(Required)

Birthdate

MM slash DD slash YYYY

SS#

Relationship to Patient(Required)

Additional Insurance Co.(Required)

Additional Group #(Required)

Assignment and Release

I certify that I, and/or my dependent(s), have insurance coverage with the insurance company or companies listed below and assign directly to the dentist all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named dentist may use my health care information and may disclose such information to the above-named insurance company or companies and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

Name of Insurance Company(ies)

Dentist Name

Signature of Patient, Parent, Guardian or Personal Representative(Required)

Please print name of Patient, Parent, Guardian or Personal Representative(Required)

Date(Required)

MM slash DD slash YYYY

Relationship to Patient(Required)

Phone Numbers

Home(Required)

Use your best primary phone number if you do not have a home phone.

Work

Ext

Alt. Phone

Spouse's Work

Best time and place to reach you

IN CASE OF EMERGENCY, CONTACT (Specify someone who does not live in your household.)

Emergency Contact Name(Required)

Relationship(Required)

Emergency Contact Phone(Required)

Emergency Contact Alt. Phone

Dental History

Reason for today's visit(Required)

Former Dentist

City/State

Date of last dental visit

MM slash DD slash YYYY

Date of last dental X-rays

MM slash DD slash YYYY

Place a mark on "yes" or "no" to indicate if you have had any of the following:

Bad breath(Required)

Yes

Bleeding gums(Required)

Yes

Blisters on lips or mouth(Required)

Yes

Burning sensation on tongue(Required)

Yes

Chew on one side of mouth(Required)

Yes

Cigarette, pipe, or cigar smoking(Required)

Yes

Clicking or popping jaw(Required)

Yes

Dry mouth(Required)

Yes

Fingernail biting(Required)

Yes

Food collection between the teeth(Required)

Yes

Foreign objects(Required)

Yes

Grinding teeth(Required)

Yes

Gums swollen or tender(Required)

Yes

Jaw pain or tiredness(Required)

Yes

Lip or cheek biting(Required)

Yes

Loose teeth or broken fillings(Required)

Yes

Mouth breathing(Required)

Yes

Mouth pain, brushing(Required)

Yes

Orthodontic treatment(Required)

Yes

Pain around ear(Required)

Yes

Periodontal treatment(Required)

Yes

Sensitivity to cold(Required)

Yes

Sensitivity to heat(Required)

Yes

Sensitivity to sweets(Required)

Yes

Sensitivity when biting(Required)

Yes

Sores or growths in your mouth(Required)

Yes

How often do you floss?(Required)

How often do you brush?(Required)

Health History

Physician's Name

Date of last visit

MM slash DD slash YYYY

Have you ever used a bisphosphonate medication? Common brand names are Fosamax, Actonel, Atelvia, Didronel, Boniva.(Required)

Yes

Have you ever taken any of the group of drugs collectively referred to as "fen-phen"? These include combinations of Ionamin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine).(Required)

Yes

Place a mark on "yes" or "no" to indicate if you have had any of the following:

AIDS/HIV(Required)

Yes

Anemia(Required)

Yes

Arthritis, Rheumatism(Required)

Yes

Artificial Heart Valves(Required)

Yes

Artificial Joints(Required)

Yes

Asthma(Required)

Yes

Back Problems(Required)

Yes

Bleeding abnormally, with extractions or surgery(Required)

Yes

Blood Disease(Required)

Yes

Cancer(Required)

Yes

Chemical Dependency(Required)

Yes

Chemotherapy(Required)

Yes

Circulatory Problems(Required)

Yes

Congenital Heart Lesions(Required)

Yes

Cortisone Treatments(Required)

Yes

Cough, persistent or bloody(Required)

Yes

Diabetes(Required)

Yes

Emphysema(Required)

Yes

Epilepsy(Required)

Yes

Fainting or dizziness(Required)

Yes

Glaucoma(Required)

Yes

Headaches(Required)

Yes

Heart Murmur(Required)

Yes

Heart Problems(Required)

Yes

Hepatitis(Required)

Yes

Hepatitis Type(Required)

Herpes(Required)

Yes

High Blood Pressure(Required)

Yes

Jaundice(Required)

Yes

Jaw Pain(Required)

Yes

Kidney Disease(Required)

Yes

Liver Disease(Required)

Yes

Low Blood Pressure(Required)

Yes

Mitral Valve Prolapse(Required)

Yes

Nervous Problems(Required)

Yes

Pacemaker(Required)

Yes

Psychiatric Care(Required)

Yes

Radiation Treatment(Required)

Yes

Respiratory Disease(Required)

Yes

Rheumatic Fever(Required)

Yes

Scarlet Fever(Required)

Yes

Shortness of Breath(Required)

Yes

Sinus Trouble(Required)

Yes

Skin Rash(Required)

Yes

Special Diet(Required)

Yes

Stroke(Required)

Yes

Swollen Feet or Ankles(Required)

Yes

Swollen Neck Glands(Required)

Yes

Thyroid Problems(Required)

Yes

Tonsillitis(Required)

Yes

Tuberculosis(Required)

Yes

Tumor or growth on head or neck(Required)

Yes

Ulcer(Required)

Yes

Venereal Disease(Required)

Yes

Weight Loss, unexplained(Required)

Yes

Do you wear contact lenses?(Required)

Yes

Women

Are you pregnant?

Yes

Due date

MM slash DD slash YYYY

Are you nursing?

Yes

Taking birth control pills?

Yes

Medications

List any medications you are currently taking and the correlating diagnosis:(Required)

Enter "None" if you are not currently taking any medications.

Pharmacy Name

Phone

Allergies

Are you allergic to any of the following?(Required)

No known allergies

Aspirin

Barbiturates (Sleeping pills)

Codeine

Iodine

Latex

Local Anesthetic

Penicillin

Sulfa

Other

Select all that apply. If none, select "No known allergies".

Other allergies or reactions(Required)

+1 (239) 997-9949

Patient Registration Form

Dental Registration and History

Patient Information

Dental Insurance

Assignment and Release

Phone Numbers

Dental History

Health History

Women

Medications

Allergies