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New Patient Registration Form

Thank you for visiting our office.  We want your visit to be pleasant and comfortable. Please help us by completing this form.

All of this information is completely confidential.

Patient Information

Full Name (Last, First, Initial):  
Preferred Name:
City ,State, Zip: ,
Phones: Home-    Work-    Cell-
E-mail Address:
Soc Sec #:
Male Female
Date of Birth:
Marital Status:
Single Married Widowed Separated Divorced
Patient Employer/Occupation:
Emergency Contact:
Spouse's Name:
Spouse's Employer/Occupation:
How did you hear about our office?

Responsible Party Information

Person Financially Responsible:
Relation to patient:
City ,State, Zip: ,
Phones: Home-    Work-
Soc Sec #:
Date of Birth:

Dental Insurance Information

Is patient covered by dental insurance?
Yes No
(If yes, please complete the following:)  
Policy Holder Name:
Relation to Patient:
City ,State, Zip: ,
Phones: Home-    Work-
Soc Sec #:
Date of Birth:
Insurance Company Name:
Insurance Company Phone:
Group #:
Subscriber ID#:
Is patient covered by additional dental insurance?
Yes No
(If yes, please complete the following:)  
Policy Holder Name:
Relation to Patient:
City ,State, Zip: ,
Phones: Home-    Work-
Soc Sec #:
Date of Birth:
Insurance Company Name:
Insurance Company Phone:
Group #:
Subscriber ID#:



It is our desire to make necessary treatment affordable to you. Please read all information and acknowledge by signing below.

As a courtesy to you, we will gladly file the patient's primary insurance claims for services rendered. Please furnish all information necessary to submit your claim. Please keep us informed of any changes to your policy.

It is imperative that the patient understands that we cannot make a totally accurate estimate of the insurance benefits. The insurance is a contract between you and your carrier. Any deductible, co-payment, or service not covered by your insurance carrier will be your responsibility and will be due when services are rendered. Rejection of the patients claim by their carrier does not relieve you of your financial obligation in our office. If your insurance denies our charges, or does not pay us in a timely manner, or if your account becomes delinquent, we reserve the right to refer your account to a collection agency and to be reported to the credit bureau.

I understand that the fee estimate listed for dental care can only be extended for a period of three months from the date of the patient examination. Any balances on your account must be paid in full before you will be seen again unless a payment arrangement has been made with billing personnel.

Returned checks will be subject to a Non-Sufficient fund fee of $35.

Rescheduling and Cancellation Guidelines

We respect your time and make every effort to remain on schedule. Please be patient if we are behind schedule, emergencies do occur. Your appointment time has been reserved especially for you. If you are late, we may not have the appropriate time to complete the procedure, therefore; we may need to reschedule your appointment to allow us the correct time to complete your dental treatment. If you feel you will not be able to keep your appointment, please give us a 24 hour notice. You will be subject to a $50.00 service charge without a 24-hour advance notice if 2 appointments are missed. If three appointments are missed, you will be dismissed from the practice for non- compliance. For appointment times over 1 hour, you will be subject to a $100 fee for every hour missed.

Agreement: I have read the above guidelines and understand my responsibility.

Signature (Parent/Guardian if under age 18) Relationship (if patient is under age 18) Date

Medical History

Patient Name: Birthdate: Date Created:
Althrough dental personnel primarily treat the area in and around your mouth, your mouth is a 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 physician's 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 medication, pills, or drugs?
Yes No
If yes
Do you take, or have you taken, Phen-Fex 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
If yes
Do you use tobacco?
Yes No
If yes
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
If yes
Do you have, or have you had, any of the following?
Yes No
AIDS/HIV Positive
Alzheimer's Disease
Artificial Heart Valve
Artificial Joint
Blood Disease
Blood Transfusion
Breathing Problems
Bruise Easily
Chest Pains
Cold Sores/Fever Blisters
Congenital Heart Disorder
Yes No
Cortisone Medicine
Drug Addiction
Easily Winded
Epilepsy or Seizures
Excessive Bleeding
Excessive Thirst
Fainting Spells/Dizziness
Frequent Cough
Frequent Diarrhea
Frequent Headaches
Genital Herpes
Hay Fever
Heart Attack/Failure
Heart Murmur
Heart Pacemaker
Heart Trouble/Disease
Yes No
Hepatitis A
Hepatitis B or C
High Blood Pressure
High Cholesterol
Hives or Rash
Irregular Heartbeat
Kidney Problems
Liver Disease
Low Blood Pressure
Lung Disease
Mitral valve Prolapse
Pain in Jaw Joints
Parathyroid Disease
Psychiatric Care
Yes No
Radiation Treatments
Recent Weight loss
Renal Dialysis
Rheumatic Fever
Scarlet Fever
Sickle Cell Disease
Sinus Trouble
Spina Bifida
Stomach/Intestinal Disease
Swelling of Limbs
Thyroid Disease
Tumors or Growths
venereal Disease
Yellow Jaundice
Yes No
Have you ever had any serious illness not listed above?
If yes
  • To the best of my knowledge, the questions on this from 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.

Dental History (New Patients Only)

Checkmark if you have ever had any of the following:
Bad breath problem Biteguard / Nightguard Canker sores in mouth
Cold sores on outer lips Dental anesthetic problems Excessive gag reflex
Fear of dental care Frequent headaches, neck aches Full dentures / Partial dentures
Oral surgery Orthodontics (braces) TMJ, jaw joint pain or treatment
Gum disease treatment
Checkmark if you currently have any of the following:
Bleeding gums Broken tooth or filling Clenching or grinding of teeth
Clicking or popping jaw Dry mouth Food packing between teeth
Loose tooth Mouth breathing Pain
Sensitivity to - heat - cold - biting Sensitivity to - sweets - pressure Sores or growths in mouth
Swelling Tired, sore or painful jaw joint Toothache
Vague ache Pain around ear
Give details and location of the above checked items:
How often do you brush?
How often do you floss?
What type toothbrush do you use?
Ultrsoft Soft Medium Hard Electric
Reason for today's visit
Former Dentist , City/State:    Phone:
Date and reason of last dental visit:
Date of last dental X-rays:
What have you liked about any dental office you've been to?
What have you liked LEAST about any dental office you've been to?


I have reviewed the information on this form and it is accurate to the best of my knowledge. I authorize and give consent for the dentist and/or team of this office to perform dental services as agreed between doctor and patient and/or guardian, including the use of local anesthetic and other medication as indicated.

Signature (Parent/Guardian if under age 18) Relationship (if patient is under age 18) Date

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