Patient Registration Form Patient Information *All fields requiredSalutation*Mr.Mrs.Ms.Dr.First Name*Last Name*Date of Birth* MM slash DD slash YYYY Registering for a child?* Yes No Person responsible for account*Other parental consent required* Yes No Mother’s name*Business Tel*Father’s name*Business Tel*Contact InformationEmail* Home Phone*Cell Phone*Work Phone*Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Preferred Location*South ElginSleepy HollowIn case of emergency, please notify:Name*Relation*Home Phone*Cell Phone*Work Phone*Contact OptionsI prefer appointment reminders by* Phone SMS (TEXT) Email Whom may we thank for referring you?*Are any other members of your family patients at our practice?* Yes No Please list all family members*Insurance Information* Yes, insurance applies to me No, insurance does not apply to me Please complete the following if you have dental insuranceName of insured/subscriber*Date of Birth* MM slash DD slash YYYY Patient's relationship to subscriber* Self Spouse Child Place of Employment*Insurance Company*Policy/Group #*Certificate/ID #*I authorize release to my dental benefits plan administrator information contained in claims and/or predeterminations* Yes 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?* Yes No Not Sure/Maybe When was your last medical checkup?* MM slash DD slash YYYY Has there been any change in your general health in the past year?* Yes No Not Sure/Maybe Please Specify*Are you taking any prescription, non-prescription medications, or herbal supplements?* Yes No Not Sure/Maybe Please list and provide dosages. If there is insufficient room, please bring a written list of all your medications to your first appointment.Do you have any allergies?* Yes No Not Sure/Maybe --select--*MedicationsLatex/Rubber ProductsOther (e.g hayfever, foods, etc)Have you ever had a peculiar or adverse reaction to any medicines or injections?* Yes No Not Sure/Maybe Please list below with approximate dates* MM slash DD slash YYYY Do you have or have you ever had asthma?* Yes No Not Sure/Maybe Do you have or have you ever had any heart or blood pressure problems?* Yes No Not Sure/Maybe Do you have or have you ever had 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/Maybe Do you have a prosthetic or artificial joint?* Yes No Not Sure/Maybe Do you have any conditions which may affect your immune system (i.e. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?* Yes No Not Sure/Maybe Please specify*Have you ever had hepatitis, jaundice, or liver disease?* Yes No Not Sure/Maybe Do you have a bleeding problem or bleeding disorder?* Yes No Not Sure/Maybe Please specify*Have you ever been hospitalized for any illnesses or operations?* Yes No Not Sure/Maybe Please specify*Do you have, or have ever had any of the following? Please check* Select All Chest pain/angina Osteoporosis Medications Mitral Valve Prolapse Shortness of Breath Rheumatic Fever Heart Attack Stroke Cancer Pacemaker Lung Disease Heart Murmur Arthritis Steroid Therapy Diabetes Tuberculosis Drug/Alcohol Dependency Seizures Thyroid Disease Stomach Ulcers Kidney Disease None of the above Are there any conditions/diseases not listed that you have or have had?* Yes No Not Sure/Maybe If yes, please specify:*Are there any diseases/medical problems that run in your family (e.g. diabetes, cancer, heart disease, etc.)?* Yes No Not Sure/Maybe If yes, please specify:*Do you smoke or chew tobacco products?* Yes No Not Sure/Maybe Are you nervous during dental treatment?* Yes No Not Sure/Maybe For women only: Are you pregnant or breastfeeding?* Yes No Not Sure/Maybe What is your expected delivery date?* MM slash DD slash YYYY Dental HistoryDo you have any specific dental concerns? Please list:*When was your last dental appointment?* MM slash DD slash YYYY How often do you see the dentist?* Not Applicable Every 3 months Every 4 months Every 6 months Only when something is bothering me Is there anything about the appearance of your teeth that you would like to change?*Have you ever whitened (bleached) your teeth? Yes No Not Sure/Maybe Do you feel uncomfortable or self-conscious about the appearance of your teeth?*Have you been disappointed with the appearance of previous dental work? I agree to receive emails with related information and updates. CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
