New Patient Enrollment Form

New Patient Registration

Please fill in the form below as it relates to the Patient
Patient’s Name *

First Name Middle Name Last Name
Patient’s Date of Birth *

Month Day Year
Sex
Weight (pounds)
An approximation is sufficient, this information is in case we need to write you a prescription
Contact Number: *

Area Code Phone Number
E-mail *
Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
In case of emergency who should we contact?
Emergency Contact: *

First Name Last Name
Relationship
Contact Number *

Area Code Phone Number
Health History

Please fill this section out to the best of your knowledge, we need the most current and updated medical history to provide the best dental care
Do you (or your child) have any of the following health conditions? *

Anemia Asthma Arthritis Anxiety Bleeding Disorder Bisphosphonate Therapy Cancer Chemo/Radiation Therapy Depression Diabetes Digestive Conditions Emotional Disorder Epilepsy/Seizures Fainting Spells Gallstones Gout Heart Disease Heart Murmur Heart Attack High Blood Pressure Hepatitis Joint Replacement Kidney Disease Liver Disease Lung Disease Neurological Disorder Rheumatic Fever Sleep Apnea/ CPAP user Stroke Thyroid Conditions Tuberculosis Venereal Disease Autism ADHD or ADD No medical conditions
Are there any other health concerns we should be aware of?
Are you (or your child) currently taking any medications? Please list name of medication and dosages below *
Have you had any surgeries or hospitalizations? Please list all previous surgical procedures and dates performed *
Please list any/all drug allergies *

Penicillin Sulfa Codeine Local Anesthetic None
Women Only: are you pregnant now or is there a chance you could be?

Yes No
Have you in the past or do you currently use tobacco products? *

Yes No
Are you currently under the care of a physician? *
If yes, please list the name and Phone number of your doctor here
Dental History

Let us know what brings you to us
What is the main reason for your visit
When was your last dental visit?
Have you had any problems with past dental treatments

Yes No
Do you/your child have dental insurance? *

Yes No
If yes, then please provide us with your dental insurance information below
Please list the name of your DENTAL insurance
Subscriber Information:

First Name Last Name
Employer Name:
ID number:
As provided on your insurance card
Group number:
As listed on your insurance card
Signature *

Clear
Should be Empty:

New Patient Registration

Health History

Dental History