Advanced Dental Implants, Prosthodontics & Family Dental Care

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Patient Registration

We realize that it is a contradiction to politely say "Welcome" and to immediately request that you complete this form in the same sentence. However, it is vital that we obtain accurate, pertinent information in order to rener the best possible treatment. Therefore, we must ask your indulgence and request the inevitable.

Contact us Contact form Registration form

Registration Form

Please complete the following form. All informtion will be kept strictly confidential. By the way, this is not an examination and no grade will be given, so if you have any questions or would like assistance, please ask. Thank-you and welcome to our office!


I. Personal Information

First Name: Last Name:      

Middle Name: Nickname:      

Salutation:      Mr.      Mrs.      Ms.      Dr.

 

Home Address:

City:      State:      Zip:

Social Security #:      Email:

Home Phone:      Work Phone:

 

Employer:

Employer Address:

City:      State:      Zip:

 

Sex:      M      F          Birthdate:      Age:

 

Spouse:      Spouse Employer:

 

Who may we thank for this referral?

 

 

Person Responsible For This Account (If patient is a minor or adult dependent)

Responsible Party:      Relationship:

Address:

City:      State:      Zip:

Phone:      Fax:

Email:

 

In the event of an Emergency, who should we contact?

Emergency Name:      Relationship:

Home Phone:      Work Phone:

 

Dental Insurance Information

Do you have dental insurance coverage?      Yes      No

Primary Insurance:      Group# / Cert#:

Name of Policy Holder:      Birthdate:      SS#:

Secondary Insurance:      Group# / Cert#:

Name of Policy Holder:      Birthdate:      SS#:

II. Medical / Dental history

Height:      Weight: lbs

YES NO
1. Are you in good health?
2. Any changes in your general health in the last year?
3. My last physical examination was on:
4. Are you now under the care of a physician?
5. The name and address of my physician is:
     
6. Have you ever been hospitalized in the past 5 years?
     If yes, please explain:
     
7. Are you allergic or have you ever experienced a reaction to any of the following?
YES NO
     Local anesthesia
     Penicillin or Other Antibiotics
     Sulfa drugs
     Barbituates, Sedatives, Narcotics
     Aspirin
     Iodine
     Codeine
     Other
8. Have YOU EVER or are you CURRENTLY taking any of the following:
YES NO
     Blood Thinners
     Blood Pressure Medications
     Insulin/Diabetes Medications
     Steroids/Cortisone
     Thyroid Medication
     Heart Medications
     Nitroclycerin
     Fenfluramine (Pondimin)
     Dexfenfluramine (Redux)
     Phentermine
     Fen / Phen
9. Please list all medications and dosages below:
YES NO
10. Do you smoke?
11. Do you drink alcohol?
12. Do you use any illicit drugs or medications?

13. Do you HAVE or have you EVER had any of the following?

GENERAL YES NO
Tire Easily, Weakness
Marked Weight Change
Night Sweats
Persistent Fever
Eruptions/Rash/Hives
Change in Skin Color
Vision Change
Glaucoma
Loss of Hearing
Ringing in Ears
Frequent Nosebleeds
Sinus Problems
 
NERVOUS SYSTEM YES NO
Stroke
Convulsions/Epilepsy/Seizures
Headaches
Numbness/Tingling
Dizziness
Fainting
Psychiatric
 
ENDOCRINE YES NO
Diabetes
Family History of Diabetes
Thyroid Condition/Goiter
 
CARDIOVASCULAR YES NO
Rheumatic Fever
Heart Murmur/Heart Defects
Chest Pain/Discomfort
Heart Attach/Heart Trouble
Shortness of Breath
Swelling of Ankles
High Blood Pressure
Low Blood Pressure
Heart Defects
Mitral Valve Prolapse
Artificial Heart Valve
Pacemaker
 
DIGESTIVE SYSTEM YES NO
Hepatitis
Jaundice
Ulcers
Change in Appetite
Bloody/Coffe Ground Vomitus
Black, Bloody or Pale Stools
Liver Disease/Cirrhosis
 
GENITO/URINARY YES NO
Kidney Disease
Frequent Urination
Burning on Urination
Urethral Discharge
Bloody Urine
Sexually Transmitted Disease
 
RESPIRATORY YES NO
Tuberculosis
Emphysema
Asthma/Hay Fever
Persistent Cough
Sputum Production/Phlegm
Cough up Bloody Sputum
Difficulty Breathing
 
BLOOD YES NO
Abnormal Bleeding
Bruise Easily
Anemia
Blood Transfusions
Aids/Arc/Hiv
 
NEOPLASMS YES NO
Cancer
Tumors or Growths
Chemotherapy/Radiation Therapy
 
BONE/MUSCLES YES NO
Arthritis/Rheumatism
Artificial Joints
 
WOMEN YES NO
Are you Pregnant?
Are you Nursing?
Are you Taking Birth Control Pills?


14. Why are you now seeking Dental Treatment?
     
YES NO
15. Did your Dentist ask you to see me?
16. Has any Dentist ever suggested that you see a Periodontist?
17. Do you feel you know and understand what causes Periodontal Disease?
18. Has a dentist ever told you that you will lose all your teeth some day?
19. Do you believe you will lose all or most of your teeth some day?
20. Do you believe that tooth loss is preventable or treatable?
21. Are you greatly concerned about losing your teeth and/or facial bone structure?
22. Do you visit your dentist regularly?
23. Do your gums bleed or feel sore?
24. Do you feel you have constant bad breath?
25. Do any of your teeth feel loose?
26. Are any of your teeth sensitive to hot, cold, sweets, or biting?
27. Have you ever noticed a change in your bite or shifting of teeth recently?
28. Do you feel that dentures are an adequate replacement for natural teeth?
29. When was the last time your teeth were cleaned or scaled?
     
YES NO
30. Do your jaws pop or click or do you have difficulty opening or closing your jaw?
31. Have you ever had braces or orthodontic treatment?
32. Do you have a tremendous fear or become overly anxious when seeing a dentist?
33. Have you ever had a bad or traumatic experience in a dental office?
     If so, explain

I certify that I have read and understand the Medical/Dental History forms above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my Doctor, or any other member of his staff, responsible for any errors or omissions that I have made in the completion of these forms.