Patient Registration Form

    Patient Information





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    Insurance Information


    YesNo



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    Secondary Insurance Information


    YesNo



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    Dental Information



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    YesNo

    YesNo

    YesNo

    YesNo

    YesNo


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    YesNo

    Health Information*


    YesNo

    YesNo

    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo

    YesNo


    YesNo


    YesNo


    Rheumatic FeverLung diseaseTuberculosisArthritisEpilepsyAngina/chest painHeart attackPacemakerStrokeAsthmaStomach ulcersDiabetesMitral valve prolapseCancerOrgan transplantHeart murmurSteroid therapyKidney diseaseOsteoporosis medications(eg., Fosamax, Actonel)

    YesNO




    Medication*


    YesNo
    Please list your current medications and reasons for taking them below:









    On a scale of 1-10, how would you rate your smile?

    12345678910

    Optimizing Your Oral Health


    In-Office WhiteningInvisalignImplantsTake-Home WhiteningVeneers/CrownsReplacing missing teethSleep Apnea and Snore GuardsLaughing GasOther

    Authorization

    I, the undersigned patient, certify that all the above medical and dental information is true to the best of my knowledge and that I have not omitted any pertinent information.
    I agree to the performing of dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anesthetics or other prescribed drugs as indicated.
    I will assume full responsibility for the fees associated with these procedures.
    I agree to the privacy policies posted in the reception area and consent to the electronic sharing of infomration with my insurance company for the purposes of processing insurance claims and the determination of benefits.
    I am aware that 2 business ays notice is required to change or cancel an appointment without charge:




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