New Patient Registration Form

Patient Full Name

Preferred Name

Patient is:

Policy Holder
Responsible Party

How did you hear about our office?

Responsible Party, if other than Patient

Responsible Party Full Name

Responsible Party Address

Responsible Party Phone

Responsible Party Cell Phone

Responsible Party Work Phone

Responsible Party Date of Birth

Responsible Party Social Security Number

Responsible Party Email

Check all that apply:

Responsible Party is also a policy holder for Patient
Primary Insurance Policy Holder
Secondary Insurance Policy Holder

Patient Information

Patient Address

Patient Phone

Patient Work Phone

Patient Cell Phone

Patient Social Security Number

Patient Birth Date

Patient Sex:

Male
Female

The best way to remind you about future appointments:

Text Message
Phone Call
Email

Dental Insurance Information

Employer Name

Employer Address

Employer Phone

Patient Student Status:

Full Time
Part Time
N/A

Insurance Policy Holder Full Name

Insurance Policy Holder Date of Birth

Insurance Policy Holder Social Security Number

Relationship to Patient:

Self
Spouse
Child
Other

Policy Holder Employer

Policy Holder Employer Address

Policy Holder Insurance Company

Policy Holder Insurance Company Phone

Medical History:

Although dental personnel primarily treat the area in and around your mouth, it is part of your entire body. Health problems that you may have or medication… [content missing]

Are you under a doctor's care now? Please Explain.

Have you ever been hospitalized or had a major operation? Please explain.

Are you taking any medications, pills or drugs? Please explain.

Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? Please explain.

Have you ever taken any blood thinning medications such as Warfarin or Coumadin? Please explain.

Do you use tobacco? Please explain.

Women: Are you

Pregnant/Trying to get pregnant?
Nursing?
Taking oral contraceptives?

Are you allergic to any of the following?

Penicillin
Sulfa Drugs
Codeine
Local Anesthetics
Latex

Please explain any other allergies or serious illnesses you have that are not listed above.

Authorization

I affirm that the information given is correct to the best of my knowledge. I understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.

I also authorize my insurance carrier to issue the dental benefits of my plan directly to this dental office. In addition, I authorize release of any information necessary to process dental insurance. I understand that I am responsible for any portion my insurance carrier does not pay.

I agree to the above terms.