Patient Registration Form

Patient Information

*All fields required




YesNo

Contact Information





In case of emergency, please notify:





Contact Options

PhoneSMSEmail

YesNo

Insurance Information

YesNo

Medical History

The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by Doctor/Patient confidentiality. The Dentist will review the questions and explain any that you do not understand. Please complete the entire form.

YesNoNot Sure/Maybe

YesNoNot Sure/Maybe

YesNoNot Sure/Maybe

YesNoNot Sure/Maybe

YesNoNot Sure/Maybe
YesNoNot Sure/Maybe
YesNoNot Sure/Maybe

YesNoNot Sure/Maybe

YesNoNot Sure/Maybe

YesNoNot Sure/Maybe
YesNoNot Sure/Maybe
YesNoNot Sure/Maybe
YesNoNot Sure/Maybe

Do you have, or have ever had any of the following? Please check.YesNoNot Sure/Maybe

YesNoNot Sure/Maybe

YesNoNot Sure/Maybe

YesNoNot Sure/Maybe
YesNoNot Sure/Maybe

YesNoNot Sure/Maybe

Dental History

Please list

Not ApplicableEvery 3 monthsEvery 4 monthsEvery 6 monthsOnly when something is bothering me