PATIENT REGISTRATION FORM

If you have an upcoming appointment with our office, please fill out the registration form ahead of your appointment.

Patient's Information

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Contact Information

Employer Information

Insurance Information

Insurance Policy Holder Information (if it is not you)

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Health History

YOUR ANSWERS ARE FOR OUR RECORDS ONLY AND WILL BE CONSIDERED CONFIDENTIAL.

Are you in good health?
Have you had any serious illnesses, hospitalizations or surgeries in the past five years?
Do you drink alcohol?
Do you use marijuana or other “street” drugs?
Do you smoke or use other tobacco products?
Are you taking any blood thinners? (Aspirin, Plavix, Coumadin, Xarelto)
Are you taking or have you ever taken Bisphosphonates for osteoporosis, multiple myeloma or other cancers? (Reclast, Fosamax, Actonel, Boniva, Aredia, Zometa, Xgeva, Prolia)

Women ONLY:

Please check any diseases or problems you have.

Do you have any other disease, condition or problem not listed above that you think the doctor should know about?

Allergies:

Are you allergic to any medications? (If yes, please mark below)

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 responsibility to inform the dental office of any changes in medical status.

Thanks for submitting, a team member will be in contact!