New Patient Registration

Patient Information

Your name Your email Phone Registering for child

Yes

No

Date of Birth Insurance Coverage

Yes

No

Emergency Contact

Name Relation Phone

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 anytime within the past year?

Yes

No

Not Sure

When was your last medical check-up? Has there been any change in your general health in the past year?

Yes

No

Not Sure

Are you taking any prescription, non-prescription medications, or herbal supplements?

Yes

No

Not Sure

Do you have any allergies?

Yes

No

Not Sure

Have you ever had a peculiar or adverse reaction to any medicines or injections?

Yes

No

Not Sure

Do you have or ever had asthma?

Yes

No

Not Sure

Do you have or ever had any heart or blood pressure problems?

Yes

No

Not Sure

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?

Yes

No

Not Sure

Do you have a prosthetic or artificial joint?

Yes

No

Not Sure

Do you have any conditions which may affect your immune system? (i.e. Leukemia, AIDS, HIV Infection, Radiotherapy, Chemotherapy)

Yes

No

Not Sure

Have you ever had hepatitis, Jaundice, or liver disease?

Yes

No

Not Sure

Do you have a bleeding problem or bleeding disorder?

Yes

No

Not Sure

Have you ever been hospitalized for any illness or operations?

Yes

No

Not Sure

Are there any conditions/diseases not listed that you have or have had?

Yes

No

Not Sure

Are there any diseases/medical problems that run in your family (e.g. diabetes, cancer, heart disease)?

Yes

No

Not Sure

Do you smoke or chew tobacco products?

Yes

No

Not Sure

Do you get nervous during dental treatment?

Yes

No

Not Sure

For women only:

Are you pregnant?

Yes

No

Not Sure

Are you breastfeeding?

Yes

No

Not Sure

Dental History

Do you have any specific dental concerns? Please list When was your last dental appointment? How often do you see the dentist?

Not Applicable

Every 3 months

Every 4 months

Every 6 months

Only when something is bothering me

Isthere anything about the appearance of your teeth that you would like to change? Have you ever whitened (bleached) your teeth?

Yes

No

Not Sure

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