Make an Appointment
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Make an Appointment | Patient Registration | Medical History Exam

Make an Appointment

First Name
Last Name
email
Phone
Date of the appointment
Preferred time

Patient Registration

PERSONAL INFORMATION
First Name		Last Name
Middle Name		Preferred Name
Patient is: Policy Holder Responsible Party
Responsible Party (if someone other than the patient)
First Name		Last Name
Middle Name		Preferred Name
Address
Address #2
City		State
ZIP Code		Pager
Home Phone		Cellular
Work Phone		Ext.
Birthday		Age
Soc. Security		Drivers Lic.
PATIENT INFORMATION
Address
Address #2
City		State
ZIP Code		Pager
Home Phone		Cellular
Work Phone		Ext.
Sex	Male Female
Marital Status	Married Single Divorced Separated Widowed
Birth date		Age
Soc. Security		Drivers Lic.
What is your beverage of choice: tea, coffee, bottled water, soft drink, juice?
Would you like to know about sedation dentistry?
Do you have an entertainment choice? CD player, iPOD, etc.?
If you could change ANYTHING about your smile, what would you change?
email		I would like to receive correspondences via email

Medical History Exam

Patient Name		Birth Date
Although 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 relationship 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, please explain:
- Have you ever been hospitalized or had a major operation? Yes No
If yes, please explain:
- Have you ever had a serious head or neck injury? Yes No
If yes, please explain:
- Are you taking any medications, pills, or drugs? Yes No
If yes, please explain:
- Have you been told that you snore or have sleep apnea? Yes No
- Do you take, or have you taken, Phen-Fen or Redux? Yes No
- Are you on a special diet? Yes No
- Do you use tobacco ? Yes No
- Do you use controlled substances? Yes No
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 Local Anesthetics
Other - If yes, please explain
Do you have, or have you had, any of the following?
AIDS/HIV Positive		Heart Trouble/Disease
Alzheimer's Disease		Hemophilia
Anaphylaxis		Hepatitis A
Anemia		Hepatitis B or C
Anginas		Herpes
Arthritis/Gout		High Blood Pressure
Artificial Heart Valve		Hives or Rash
Artificial Joint		Hypoglycemia
Asthma		Irregular Heart Beat
Blood Disease		Kidney Problems
Blood Transfusion		Leukemia
Breathing Problems		Liver Disease
Bruise Easily		Low Blood Pressure
Cancer		Lung Disease
Chemotherapy		Mitral Valve Prolapse
Chest Pains		Pain in Jaw Joints
Cold Sores/Fever Blisters		Parathyroid Disease
Congenital Heart Disorder		Psychiatric Care
Convulsions		Radiation Treatments
Cortisone Medicine		Recent Weight Loss
Diabetes		Renal Dialysis
Drug Addiction		Rheumatic Fever
Easily Winded		Rheumatism
Eating disorder		Scarlet Fever
Emphysema		Shingles
Epilepsy or Seizures		Sickle Cell Disease
Excessive Bleeding		Sinus Trouble
Excessive Thirst		Spina Bifida
Fainting Spells/Dizziness		Stomach/Intestinal Disease
Frequent Cough		Stroke
Frequent Diarrhea		Swelling of Limbs
Frequent Headaches		Thyroid Disease
Genital Herpes		Tonsillitis
Glaucoma		Tuberculosis
Hay Fever		Tumors or Growths
Heart Attack/Failure/Surgery		Ulcers
Heart Murmur		Venereal Disease
Heart Pace Maker		Yellow Jaundice
Have you ever had any serious illness not listed above? Yes No
If yes, please explain
Comments
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsability to inform the dental office of any changes in medical status.
Name of the patient, parent or guardian
	Date