Patient Information

*All fields required

Name *
Name
Registering for child? *
Date of Birth *
Date of Birth
Home Phone *
Home Phone
Cell Phone
Cell Phone
Work Phone *
Work Phone
Address *
Address
EMERGENCY CONTACT
Emergency Contact Home Phone *
Emergency Contact Home Phone
Emergency Contact Cell Phone *
Emergency Contact Cell Phone
Emergency Contact Work Phone *
Emergency Contact Work Phone
Contact Options *
I prefer appointment reminders by
Are any other members of your family patients at our practice? *
INSURANCE INFORMATION
Do you use insurance? *
MEDICAL HISTORY
The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by Doctor/Patient confidentiality. The Dentist will review the questions and explain any that you do not understand. Please complete the entire form.
Are you being treated for any medical condition at the present or any time within the past year? *
When was your last medical check-up? *
When was your last medical check-up?
Has there been any change in your general health in the past year? *
Are you taking any prescription, non-prescription medications, or herbal supplements? *
Do you have any allergies? *
Have you ever had a peculiar or adverse reaction to any medicines or injections? *
Do you have or ever had asthma? *
Do you have or ever had any heart or blood pressure problems? *
Have you ever/do you have an artificial heart valve, infection of the heart (i.e.infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant? *
Do you have a prosthetic or artificial joint? *
Do you have any conditions which may affect your immune system? (i.e. Leukemia, AIDS, HIV Infection, Radiotherapy, Chemotherapy) *
Have you ever had hepatitis, jaundice, or liver disease? *
Do you have a bleeding problem or bleeding disorder? *
Have you ever been hospitalized for any illnesses or operations? *
Do you have, or have ever had any of the following? Please check.
Are there any conditions/diseases not listed that you have or have had? *
Are there any diseases/medical problems that run in your family (eg-diabetes, cancer, heart disease)? *
Do you smoke or chew tobacco products? *
Are you nervous during dental treatment? *
For women only: Are you pregnant? *
For women only: Are you pregnant? *
DENTAL HISTORY
When was your last dental appointment? *
When was your last dental appointment?
How often do you see the dentist? *
Have you ever whitened (bleached) your teeth? *
Have you felt uncomfortable or self-conscious about the appearance of your teeth? *
Have you been disappointed with the appearance of previous dental work? *