Patient registration 2023

Welcome to FIRST IMPRESSIONS! Thank you for doing the heavy lifting and filling out these forms.
Name*

First NameMiddle NameLast Name
Preferred Name/Nickname
Birth Date*

MonthDayYear
Sex*

MaleFemale

Is there a possibility of pregnancy?

YesNo
Expected delivery date:
Are you nursing?

YesNo
Note: antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Please consult with your physician/gynecologist for assistance regarding additional methods of birth control.
Are you taking birth control pills?

YesNo

Phone Number*

Area CodePhone Number
Cell Phone Number*

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Social Security Number*
E-mail*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Whom may we thank for referring you?*
i.e. Person's Name, Google, Drive by, Word of Mouth, Facebook, etc.
Notify in case of emergency
Best phone number for emergency contact

Area CodePhone Number

How would you rate your smile? 1 being Worst and 5 being Best:

	1	2	3	4	5

1 is Worst, 5 is Best

Please indicate any of the following problems by checking the corresponding box:

Is there anything else you think we should know about your dental health or previous dental experiences?

Medical History
Do you have, or have you had, any of the following diseases, medical conditions, procedures, or habits. Check all that apply:

Have you had any joint replacement surgery?*

YesNo
What joint(s) have you had replaced?
Date of Surgery

MonthDayYear
Does your orthopedic surgeon want you to take pre-medication antibiotics before any dental treatment?

**If you are not sure, please contact your surgeon's office and find out. Please have them prescribe the pre-medication antibiotic that they would like you to take before your dental appointment.

Are you taking immunosuppression medication or are you actively being treated for a cancer or malignancy?*

YesNo
Date of the start of treatment

MonthDayYear
Date of the end of treatment

MonthDayYear

Do you take or have you taken any of these medications?

Humira (adalimumab)Enbrel (etanercept)Remicade (infliximab)Simponi (golimumab)Cimzia (certolizumab pegol)

Please tell us any other information that you feel is important concerning your health.

Medications

Please use the boxes below to list your medications.

Please type the name of the medication and the reason you are taking it in the boxes below.

Example: propranolol high blood pressure
Click "Add More" to extend the list. Please tell us all the medications you are taking. Thank You!
On the day of your dental appointment, please take all regularly scheduled medications.

Allergies
Are you allergic or have you had a reaction to:

LatexAspirinSulfa DrugsPenicillin/AmoxicillinCodeine/Vicodin/Norco or other narcotic drugsI do not have any known allergies
Please use the boxes below to list your allergies.

Click the "Add More" to generate another line for the list.
Please list any other medications that you may be allergic to.

Consent for Dental Treatment and Dental Implant Surgery
Please read the consent form, enter the date, and place your signature in the space provided. You may print a copy of this form if you would like.

Thank you!
Consent for Dental Treatment & Dental Implant Surgery*
Please use your computer mouse to sign your name in the space below. If you are using a tablet or smart phone, you can use a stylus or your finger to create your signature. Thank you!
Signature*

Clear
Please Enter Today's Date:

Authorization
Please click on the link below, read the authorization form, and check the box to accept the terms of the authorization.

Thank you!
Authorization for Treatment Form*

Notice of Privacy Practices
Click on the link to read the notice of privacy practices. By clicking the checkbox, you acknowledge that you have received this notice. You may print a copy of the privacy notice if you would like.

Thank You!
Notice of Privacy Practices*

HIPAA Consent and Treatment Communication
Please click on the link to read the HIPAA Consent form. By clicking the checkbox, you acknowledge that you have read the HIPAA consent form and agree to the terms included in the form.

Thank you!
HIPAA Consent Form*
Please list the names and the relationship of people that we may communicate with regarding your dental treatment. This communication can be through the use of telephone, mail, e-mail, texting, or other means.

Thank You!
Please provide the name(s) of the person(s) that we may discuss your health and dental care with:

Patient Financial Responsibility
Please click on the link to read the Patient Financial Responsibility form. By clicking on the checkbox, you agree to the terms that are listed in the form. You may print a copy of this form if you would like.

Thank You!
Patient Financial Responsibility*

Finally Finished!
Thank you very much for taking the time to fill out all the information on this form. We appreciate your time. You've just taken the first step towards a healthy smile and a lifelong better you!
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Welcome to FIRST IMPRESSIONS! Thank you for doing the heavy lifting and filling out these forms.