Online Registration - Page 1 of 2

Patient Information

Patient Name:
Gender: Family Status:
Social Security #: Birth Date:
Phone:
E-Mail Address:
Address:
 

Health Information

Date of Last Dental Visit: Reason for first visit with us:
Is there anything about your smile you would like to change:
Have you ever had any of the following? Please check those that apply:
- Date -
Please list all medications you currently take and what they are used for (including natural remedies):
Ever taken bone-density medication?
If yes, prescribed by who? when? still taking?
What pharmacy do you use?
Have you ever had any complications following dental treatment?
If yes, please explain:
Have you needed any type of major surgery?
If yes, please explain with approximate dates:
Name of Primary Care Doctor: Phone:
Do you have any health problems that need require more than "routine" healthcare?
If yes, please explain:
Seeing a specialist for these health problems? Specialist Info:
Do you use tobacco in any form?
If yes, for how long? Quit?
Women: Are you pregnant?
Hormone Use/Birth Control?
Breast Feeding?
Please list 2 Emergency Contacts:
Name/Relationship: Number:
Name/Relationship: Number:

Online Registration - Page 2 of 2

Head of Household

The following is for the person responsible for payment:
Name:
 
 
Social Security #: Birth Date:
Phone:
Address:
 

Referral Information

Whom may we thank for referring you to our practice?

Employment Information

The following is for:
Employer Name: Occupation:
Address:
Phone:

Insurance Information

Primary
Name of Insured:
Is insured a patient?
Insured's Birth Date: ID #: Group #:
Insured's Address:
Insured's Employer Name:
Address:
Patient's relationship to insured:
Insurance Plan Name and Address
Secondary
Name of Insured:
Is insured a patient?
Insured's Birth Date: ID #: Group #:
Insured's Address:
Insured's Employer Name:
Address:
Patient's relationship to insured:
Insurance Plan Name and Address

Office Hours:

Monday 8am - 4pm
Tuesday 8am - 6pm
Thursday 8am - 4pm
Friday 8am - 2pm
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