Patient Registration

Patient Registration Form


The following form is the online version of our New Patient Registration Form. Your typed name, birth date, and today's date will act as your electronic signature. Please note that use of your Social Security number is limited to the submission of insurance information and claims and to verify the privacy of your record. The form should take approximately 10 minutes to complete.

Patient Information
Patients Name:
Birth Date: (mm/dd/year)
Age:
Gender:
Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Cell Phone:
Email Address: *
Employer's Name:
Employer's Address:
Patient's Dentist:
Physician/Pediatrician:
Marital Status:
School:
Sports/Interests:
How did you hear about our office?
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Responsible Party Information: (if different from above)
Responsible Party Name:
Relationship to Patient:
Marital Status:
Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Contact you at work?
Cell Phone:
Email Address: *
Birth Date: (mm/dd/year)
Employer's Name:
Employer's Full Address:
Secondary Responsible Party:
Relationship to Patient:
Cell Phone:
Work Phone:
Contact at work OK?
Birth Date: (mm/dd/year)**
Employer's Name:
Employer's Full Address
Email Address: *
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Emergency Information:
Name of nearest relative not living with you:
Full Address:
Home Phone:
Work Phone:
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Insurance Information:
YesNo
Do you have Orthodontic Insurance?
Do you have more than one Insurance carrier?
Primary Coverage Employee name:
Birth Date: (mm/dd/year)
Employer's Name:
Name of Insurance Co:
Union/ID Local:
Group:
Insurance Phone:
Secondary Coverage
Employee name:
Birth Date: (mm/dd/year)
Employer's Name:
Name of Insurance Co:
Union/ID Local:
Group:
Insurance Phone:
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Health History:
YesNo
Is the patient in good health?
If no, please explain:
Is the patient under a physicians care?
If yes, please explain:
Is the patient taking medications?
If yes, please explain:
If female, is the patient pregnant or suspect of pregnancy?
If yes, how many months along?
Has the patients tonsils and/or adenoids been removed?
If yes, which removed?
Does the patient pre-medicate with antibiotics prior to dental cleanings?
If yes, what medicine is used?
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Has the patient had any of the illnesses listed below?
YesNo
AIDS/ARC:
Allergies:
Anemia:
Angina:
Asthma:
Bone Disorder:
Cancer:
Cold Sores:
Diabetes:
Dizzy Spells:
Epilepsy:
Fainting:
Fever Blisters:
GI Disorder:
Headaches:
Herpes:
Heart Murmur:
Heart Problem:
High Blood Pressure:
Kidney Problems:
Liver Problems:
Low Blood Pressure:
Nervous Disorder:
Prolonged Illness:
Pneumonia:
Radiation:
Rheumatic Fever:
Tuberculosis:
Venereal Disease:
Other:
Is the patient allergic to any medication?
If yes, what medication(s):
Is the patient allergic to latex or any metal?
If yes, what?
Does the patient's jaw pop, click, lock or hurt during chewing?
If yes, please explain:
Has the patient been involved in any accidents involving the face, teeth or mouth?
If yes, please explain:
Does the patient have any missing or extra permanent teeth?
Has the patient had any disease, condition or problem not listed that we should know about?
If yes, please explain:
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Please check any habits (current or in the past):
Tongue/thumb Sucking:
Night Grinding:
Mouth Breathing:
Nail Biting:
Lip Biting:
Pencil Biting:
Teeth Clenching:
Other:
Last Dental Checkup: (mm/dd/year)
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Payment Authorization:
AUTHORIZATION TO PAY BENEFITS TO DENTIST (Orthodontist)
I hereby authorize payment directly to the below named dentist of the Group Insurance Benefits otherwise payable to me.
  • Name:
  • Date of Birth:
  • Today's Date:

*Email addresses will never be sold or rented to a third party
**Used to verify insurance and can be given to us at your first appointment rather than entered online.


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