Patient Registration Adult Form

Patient Registration (Adult)

Name:

First

Last

Sex

Male Female

Email:

Address:

Street Address

City:

State:

ZIP Code:

Birthday:

Social Security:

0 of 11 max characters

Cell Phone or Home Phone:

Employer:

General Dentist:

Last Visited:

Who may we thank for referring you to our office?:

Marital Status

Single
Married
Widowed
Divorced
Separated
Domestic Partners

Name of Spouse:

Insurance Information

Policy Owner's Name:

First

Last

Policy Owner's Subscriber ID:

0 of 11 max characters

Policy Owner's Birthdate:

Employer's Address:

Street Address

City:

State:

ZIP Code:

Insurance Company:

Insurance Phone No:.

Medical History

Are you under the care of a physician?

Yes No

If Yes, please explain:

Phone:

Last Visited:

Are you pregnant?

Yes No

If Yes, how many weeks:

Have you ever experienced jaw joint pain/ discomfort (TMJ/TMD)?

Yes No

Do you have any missing or extra permanent teeth?

Yes No

Have you ever had an injury to : (select all that apply)

Teeth Mouth Chin

Do you have speech problems?

Yes No

If Yes, please explain:

Do your gums bleed?

Yes No

Do you smoke?

Yes No

Do you like your smile?

Yes No

Does/Have you ever had any of the following habits?

Lip Sucking/Biting

Nail Biting

Mouth Breather

Tongue Thrusting

Clenching/Grinding Teeth

Prolonged Bottle/Pacifier

Thumb/Finger Sucking

Are you allergic to any of the following?

Aspirin

Erythromycin

Codeine

Penicillin

Tetracycline

Any Metals/Plastics

Other Allergies/Sensitivities:

List all drugs you are currently taking:

List any serious medical condition(s) treated:

Signature

I understand that the information that I have provided is correct to the best of my knowledge, and that it will be held in the strictest of confidence.

Name of person filling out this form:

First

Last

Date: