New Patient Registration

First Name *

Last Name *

Address

City

US States

Zip

Cell/Home Phone *

Work Phone

Date of Birth

Email

Whom May We Thank For Referring You? *

Sex

Male
Female

Name of Policy Holder

Date of Birth of Policy Holder

Insurance Company

Insurance Address

City

US States

Zip

Phone

Member ID/Social Security Number

Are You Under The Care Of A Physician?

Yes
No

If Yes, Physician Name

Physician Phone Number

Have You Been Hospitalized In The Last 5 Years?

Yes
No

Have You Ever Had A Serious Head Or Neck Injury?

Are You Taking Any Medications? Including Over The Counter *

Yes
No

Please List All Medications

Do You Take, Or Have You Taken Phen-Fen or Redux?

Yes
No

Have You Ever Taken Fosamax, Boniva, Actonel, Or Any Other Medications Containing Bisphosphonates

Yes
No

Are You On A Special Diet?

Yes
No

Do You Use Tobacco?

Yes
No

Do You Use Controlled Substances?

Yes
No

For Women Only:

Pregnant
Nursing
Taking Birth Control

Are You Allergic To Any Of The Following?

If Yes, Please List Allergies

Please Check If You Have The Following

Other:

Do Your Gums Bleed While Brushing?

Yes
No

Are Your Teeth Sensitive To Hot or Cold?

Yes
No

Are Your Teeth Sensitive To Sweet Or Sour Liquids/Foods?

Yes
No

Do You Feel Pain In Any Of Your Teeth?

Yes
No

Do You Have Any Sores Or Lumps In Your Mouth?

Yes
No

Have You Ever Suffered Trauma To Your Face Mouth Or Jaw?

Yes
No

Does Your Jaw Ever Click, Pop, Crackle Or Ache?

Yes
No

Do You Have Pain In Your Jaw Joint, Ear Or Side Of The Face?

Yes
No

Do You Have Difficulty Opening Or Closing Your Mouth?

Yes
No

Do You Have Difficulty Chewing?

Yes
No

Do You Have Frequent Headaches?

Yes
No

Do You Clench Or Grind Your Teeth?

Yes
No

Do You Bite Your Lips Or Cheeks Frequently?

Yes
No

Have You Had Problems With Previous Dental Work?

Yes
No

Have You Ever Had Braces?

Yes
No

How Many Times A Day Do You Brush Your Teeth?

Once
Twice

How Often Do You Floss?

Daily
Weekly
Not At All

Do You Use A Manual Brush Or Electric?

Yes
No

Do You Use Any Type Of Mouth Rinse?

Yes
No

Goals For Your Mouth, Teeth And Smile:

If You Could Change Anything About Your Smile, What Would That Be?

Single Checkbox Field

I certify that I have read and understand the above information. To the best of my knowledge, the above questions have been answered accurately. I understand that providing false or incorrect information can be dangerous to my health.

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