Patient Registration
Name
How did you hear about us?
Do you currently have an appointment with us?
Date of Birth
-
Month
-
Day
Year
Date
Gender
Preferred Pronouns
*
SS#
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
Name
*
Relation
*
Phone Number
*
Please enter a valid phone number.
Responsible Party
If different than patient
Name
Relation to patient
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Information
Primary Insurance Company
Subscriber Name
Date of Birth
-
Month
-
Day
Year
Date
Employer
Relation to Patient
Group #
ID #
Secondary Insurance Company
Subscriber Name
Date of Birth
-
Month
-
Day
Year
Date
Employer
Relation to Patient
Group #
ID #
Dental History
How would you rate your overall dental health?
Excellent
Good
Fair
Poor
Previous Dental Office
Please check all that apply
Fear of dental treatment
Complications from dental treatment
Trouble getting numb
Reaction to local anesthetic
Braces/Orthodontic treatment
Teeth removed, or lost to injury
Bleeding/Painful Gums
Treated for gum disease or bone loss
Unpleasant taste or odor
Teeth becoming loose on their own
Any cavities in the past 3 years
Teeth sensitive to hot/cold
Pain in your jaw joints
Difficulty Chewing
Ever worn/wear a sleep appliance
Wanted to change the appearance of your teeth
Any other concerns or explanations
Submit
Should be Empty: