New Patient Registration "*" indicates required fields Today's Date MM slash DD slash YYYY Name:* First Middle Initial Last Preferred Name: Patient Is:* Policy Holder Responsible Party Responsible PartyName* First Middle Initial Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home PhoneWork PhoneCell PhoneDate of Birth MM slash DD slash YYYY SSN#Driver's License #Insurance Holder* Responsible Party is also a Policy Holder for Patient Primary Insurance Holder Secondary Insurance Policy Holder Patient InformationAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home PhoneWork PhoneCell PhoneGender: Male Female Marital Status: Married Single Divorced Separated Widowed Date MM slash DD slash YYYY NumberNumberNumberEmail Email preference I would like to recieve correspondences via Email. Employment Status Full Time Part Time Retired Student Status Full Time Part Time Medicaid ID Preferred Dentist Employer ID Preferred Pharmacy Carrier ID Preferred Hygenist Emergency Contact #Primary Insurance InformationName of Insured First Last Relationship to Insured Self Spouse Child Other Insured Soc. Sec.Insured Birth Date MM slash DD slash YYYY Untitled Ins. Company Employer Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Ins. Company Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Secondary Insurance InformationName of Insured First Last Relationship to Insured Self Spouse Child Other Insured Soc. Sec.Insured Birth Date MM slash DD slash YYYY Untitled Ins. Company Employer Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Ins. Company Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Medical HistoryAlthough dental personnel primarily treat the area in and around your mouth, your mouth is part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.Are you under a physicians care now? Yes No If yes... Have you ever been hospitalized or had a major operation? Yes No If yes... Have you ever had a serious head or neck injury? Yes No If yes... Are you taking any medications, pills, or drugs? Yes No If yes... Do you take, or have you taken, Phen-Fen or Redux? Yes No If yes... Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? Yes No If yes... Are you on a special diet? Yes No Do you use tobacco? Yes No Do you use controlled substances Yes No If yes... Women: Are you... Pregnant / Trying to get pregnant? Nursing? Taking oral contraceptives? Are you allergic to any of the following? Aspirin Penicillin Codeine Acrylic Metal Latex Sulfa Drugs Local Anesthetics Other If Other... Do you have, or have you had, any of the following?AIDS/HIV Positive Yes No Cortisone Medicine Yes No Hemophilia Yes No Radiation Treatments Yes No Alzheimer's Disease Yes No Diabetes Yes No Hepatitis A Yes No Recent Weight Loss Yes No Anaphylaxis Yes No Drug Addiction Yes No Hepatitis B or C Yes No Renal Dialysis Yes No Anemia Yes No Easily Winded Yes No Herpes Yes No Rheumatic Fever Yes No Angina Yes No Emphysema Yes No High Blood Pressure Yes No Rheumatism Yes No Arthritis / Gout Yes No Epilepsy or Seizures Yes No High Cholesterol Yes No Scarlet Fever Yes No Artificial Heart Valve Yes No Excessive Bleeding Yes No Hives or Rash Yes No Shingles Yes No Artificial Joint Yes No Excessive Thirst Yes No Hypoglycemia Yes No Sickle Cell Disease Yes No Asthma Yes No Fainting Spells/Dizziness Yes No Irregular Heartbeat Yes No Sinus Trouble Yes No Blood Disease Yes No Frequent Cough Yes No Kidney Problems Yes No Spina Bifida Yes No Blood Transfusion Yes No Frequent Diarrhea Yes No Leukemia Yes No Stomach/Intestinal Disease Yes No Breathing Problems Yes No Frequent Headaches Yes No Liver Disease Yes No Stroke Yes No Bruise Easily Yes No Genital Herpes Yes No Low Blood Pressure Yes No Swelling of Limbs Yes No Cancer Yes No Glaucoma Yes No Lung Disease Yes No Thyroid Disease Yes No Chemotherapy Yes No Hay Fever Yes No Mitral Valve Prolapse Yes No Tonsilitas Yes No Chest Pains Yes No Heart Attack/Failure Yes No Osteoporosis Yes No Tuberculosis Yes No Cold Sores/Fever Blisters Yes No Heart Murmur Yes No Pain in Jaw Joints Yes No Tumors or Growths Yes No Congenital Heart Disorders Yes No Heart Pacemaker Yes No Parathyroid Disease Yes No Ulcers Yes No Convulsions Yes No Heart Trouble/Disease Yes No Psychiatric Care Yes No Venereal Disease Yes No Yellow Jaundice Yes No Have you ever had any serious illness not listed above? Yes No Untitled CommentsTo the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.PhoneThis field is for validation purposes and should be left unchanged.