Adult Registration Form

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We would like to welcome you to our office. In an effort to provide the best service, we ask you to fill out this form as completely as possible.

Thank you!

Adult Registration Form - Dental 2
* required field

PATIENT INFORMATION

Sex *








SPOUSE - ADDITIONAL CONTACT INFORMATION

Primary phone number

Secondary Phone Number

Work Phone



DENTAL INSURANCE

Primary Insurance Information







Secondary Insurance Information








Medical History

Are you currently being treated by a physician?





Do you have any allergies to medications?
Are you currently taking any prescription or over-the-counter medications?
Have you ever taken medications for treatment of Osteoporosis?
Have you ever taken any appetite suppressants (Fen-Phen, Dexfenfluramine, Fenfluramone) or others?)
(Women) Are you pregnant?
Have your tonsils and/or adenoids been removed?

DENTAL HISTORY

Have you ever been evaluated for orthodontic treatment?

Have you ever experienced jaw joint pain (TMJ/TMD?)
Do you have any missing or extra permanent teeth?
Have you had an injury to (select all that apply)
Please explain injury:

Do you have speech problems?
If yes, explain:

Do you smoke?
Have you ever had gum disease or periodontal treatment?If yes, please explain:
Do you like your smile?
Do you have or have you ever had any of the following habits?









Emergency Contact



PURPOSE OF CONSENT (HIPPA)

I understand that the information I have provided is correct to the best of my knowledge, that it will be held in the strictest of confidences and it is my responsibility to inform this office of any changes in my medial status. I understand where appropriate, credit bureau reports may be obtained.