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Smiles for Miles Dentistry - Smiles for Miles Dentistry

New Patient Registration

New Patients Registration Form

    Patient Information
    Registering for child
    Yes
    No
     Insurance Coverage
    Yes
    No
    Emergency Contact
    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?
    Has there been any change in your general health in the past year?
    Are you taking any perscription, non-perscription 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 illness or operations?
    Are there any conditions/diseases not listed that you have or have had?
    Are there any diseases/medical problems that run in your family (e.g. diabetes, cancer, heart disease)?
    Do you smoke or chew tobacco products?
    Do you get nervous during dental treatment?
    For women only: Are you pregnant?
    For women only: Are you breastfeeding?
    Dental History
    How often do you see the dentist?
    Have you ever whitened (bleached) your teeth?