New Patient Enrollment Form

New Patient Registration

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

First NameMiddle NameLast Name
Patient’s Date of Birth*

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

Area CodePhone Number
E-mail*
Address:*

Street Address

Street Address Line 2

CityState / Province

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

First NameLast Name
Relationship
Contact Number*

Area CodePhone 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?*

AnemiaAsthmaArthritisAnxietyBleeding DisorderBisphosphonate TherapyCancerChemo/Radiation TherapyDepressionDiabetesDigestive ConditionsEmotional DisorderEpilepsy/SeizuresFainting SpellsGallstonesGoutHeart DiseaseHeart MurmurHeart AttackHigh Blood PressureHepatitisJoint ReplacementKidney DiseaseLiver DiseaseLung DiseaseNeurological DisorderRheumatic FeverSleep Apnea/ CPAP userStrokeThyroid ConditionsTuberculosisVenereal DiseaseAutismADHD or ADDNo medical conditionsOther
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*

PenicillinSulfaCodeineLocal AnestheticNoneOther
Women Only: are you pregnant now or is there a chance you could be?

YesNo
Have you in the past or do you currently use tobacco products?*

YesNo
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

YesNoOther
Do you/your child have dental insurance?*

YesNo
If yes, then please provide us with your dental insurance information below
Please list the name of your DENTAL insurance
Subscriber Information:

First NameLast 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