PAtient Registration Form

Patient Information


Which of the following methods do you prefer us to communicate you with?
(By selecting the method(s), you will give us consent to contact you via phone or email (or both).

Where did you hear about us?

Insurance Information

Coverage for

Patient's Relationship to insured

Financial Information

Method of Payment
Person responsible for financial matters

Health Information

Medical History (This information will remain confidential)

Are you presently under the care of a physician?
Have you ever been hospitalized?
Are you taking any drugs or medication at this time?
Have you ever had any adverse effects to any of the following:


Are you Pregnant?

Using birth control?

Do you suffer from any allergies? (Hay fever, latex, etc.)
Do you bruise easily or have prolonged bleeding?
Do you smoke? How much per day?
Do you drink alcohol? How often?
Do you use any recreational drug?
Have you ever fainted, had shortness of breath or chest pains?
Have you ever had any of the following? Please check those that apply: (all of your answers will be confidential)

Dental History

What is the reason for today’s visit?
Do you have a dentist? if yes, enter your dentist name
How frequently do you see a dentist?
Have you ever had any complications following dental treatment?
Are your teeth sensitive to:
Do your gums bleed when:
Do your gums feel swollen or tender?
Do you have bad breath or a bad taste in your mouth?
Do your jaws crack, pop, or grate when you open widely?
Do you grind or clench your teeth?
Have you ever had local anesthetic (freezing)?
Any complications?
Have you ever had any of the following?

General Release

I, the undersigned, understand that the information contained in the medical and dental history is important to my treatment. I certify that all the information I have completed is correct and that I have not knowingly omitted data. I consent to the release of medical information from my medical doctor or other health care provider as is required by this dental office. I authorize this dental office to perform diagnostic procedures as may be required to determine necessary treatment. I understand that it is my responsibility to pay for dental treatment for both myself and my dependents. I assume all responsibility for fees associated with my dental treatment or dental diagnostic procedures. I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form.

By checking this checkbox, I hereby understand and agree to the conditions of treatment and payment mentioned above.

Book Your Appointment

Preferred Day of the Week
Preferred Time of the Day