New Patient Registration Form

#1 PATIENT REGISTRATION
Please Complete The Following Confidential Information:

If this appointment is for you start here:
Date*

MonthDayYear
Date
Name*
Prefer to be called
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Cell Phone*

Area CodePhone Number
E mail Address*
example@example.com
Birth Date*

MonthDayYear
Date
Soc. Sec #
Choose One

MarriedSingleDivorcedWidowed
CHILD

If this appointment is for your child start here
Date

MonthDayYear
Date
Name
Prefer to be called
Guardian at Appointment
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date

MonthDayYear
Date
Soc. Sec #
Phone Number

Area CodePhone Number
School
PRIMARY INSURANCE CARRIER
Employee
Benefit Company
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Group #
Employee #
Emp Social Security #
DOB:

MonthDayYear
Date
Date Employed

MonthDayYear
Date
SECONDARY INSURANCE CARRIER
Employee:
Benefit Company
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Group #
Employee ID #
Emp. Social Security #
DOB:

MonthDayYear
Date
Date Employed

MonthDayYear
Date
GETTING TO KNOW YOU
Is another family member or relative a patient at our office?:
THEIR NAME
Whom can we thank for referring you?
NAME
Former Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Person to Contact for Emergency
Phone Number

Area CodePhone Number
Emergency Contact's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Closest Relative Not Living With You
Relative's Phone Number

Area CodePhone Number
Relative's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
ACCOUNT INFORMATION
Person Financially Responsible For Account
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
DOB:

MonthDayYear
Date
SS#
Bank
Branch
Account #
Driver's License
Your Occupation
Employer
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Telephone

Area CodePhone Number
Your Spouses Name
Spouses Occupation
Spouses Employer
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Telephone

Area CodePhone Number
#2 CONSENT FOR TREATMENT
1. I hereby authorize doctor or designated staff to take x-rays, study models, photographs and any other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of
Name of Patient's*
name of patient
dental needs.

2. Upon such diagnosis, I authorize doctor to perform recommended treatment mutually agreed upon by me and to employ such assistance as needed to provide proper care.

3. I agree to allow the use of diagnostic adjuncts to communicate with other dental professionals to assist in my care and with insurance companies to allow benefits and for educational purposes and limited publication.

4. I fully understand that I agree to the use of local anesthetics, sedative and other medications as necessary and previously agreed to by me. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a recital of possible complications.

5. We are pleased to reserve time uniquely for you. We will not make another person’s appointment at your reserved time. Since a scheduled appointment is a commitment of time between you and our practice, if you find that you cannot keep your scheduled appointment, we ask you to provide a minimum of forty- eight business hours notice to us so we may schedule another patient in need of treatment. If you fail to attend at your reserved time, we may see you on a daily space available basis, rather than by reservation. As an alternative we may also accept a non refundable prepayment for your reservation of time.
I give Dr. Korwin and his staff permission to send treatment recommendations, health related information as well as billing statements via secure email

YesNo
I have been involved with a legal claim or lawsuit involving a medical/dental provider

YesNo
Patient Name:*
Patient's Signature*

Clear
Sign Here
Date*

MonthDayYear
Date
Responsible Party Name:
Relationship to Patient:
Date

MonthDayYear
Date
HIPPA

Acknowledgement of Receipt of Notice of Privacy Practices
"You may refuse to sign this Acknowledgement"
I, {name7} have received a copy of this office's Notice of Privacy Practices.
Name of Patient
Signature:

Clear
Sign Here
Date:

MonthDayYear
Date
#3 DENTAL HISTORY
Patient Name*
Welcome! So that we may provide you with the best possible care, please complete both sides of this medical/ dental history form. All information is completely confidential:
What is the reason for your visit today?
Date of Last Dental Visit

MonthDayYear
Date
Date of Last Dental Cleaning

MonthDayYear
Date
Date of Last Full Mouth X-Rays

MonthDayYear
Date
What was done at your last dental visit?
Previous Dentist's Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
How often do you have dental examinations?
How often do you brush your teeth?
How often do you floss?
What other dental aids do you use? (Electric Brush, toothpick, etc.)
Do you have any dental problems now?

YesNo
If yes, please describe:
Are any of your teeth sensitive to:
Hot or cold?*

YesNo
Sweets?*

YesNo
Biting and chewing?*

YesNo
Have you noticed any mouth odors or bad tastes?*

YesNo
Do you frequently get cold sores, fever blisters or any other oral lesions?*

YesNo
Do your gums bleed or hurt?*

YesNo
Have your parents experienced gum disease or tooth loss?*

YesNo
Have you noticed any loose teeth or change in your bite?*

YesNo
Does food tend to become caught in between your teeth?*

YesNo
if yes, where?
Do you:
Clench or grind your teeth while awake or asleep?*

YesNo
Bite your lips or cheeks regularly?*

YesNo
Hold foreign objects with your teeth (pencils, pipe, pins, nails, fingernails)?*

YesNo
Mouth breath while awake or asleep??*

YesNo
Have tired jaws, especially in the morning?*

YesNo
Smoke/chew tobacco?*

YesNo
If yes, how many packs a day?
If yes, how many years?
Do you feel nervous about having dental treatment?*

YesNo
If so what is your biggest concern?
Have you ever had an upsetting dental experience?*

YesNo
If yes, please describe
Have you ever had:
Orthodontic treatment?*

YesNo
Oral Surgery?*

YesNo
Periodontal treatment?*

YesNo
Your teeth ground or the bite adjusted?*

YesNo
A bite plate or mouth guard?*

YesNo
A serious injury to the mouth or head?*

YesNo
If so, please describe
Have you experienced:
Clicking or popping of the jaw?*

YesNo
Pain (joint, ear, side of face)?*

YesNo
Difficulty in opening or closing mouth?*

YesNo
Difficulty in chewing on either side of the mouth?*

YesNo
Headaches, neck aches or shoulder aches?*

YesNo
Sore muscles (neck, shoulders?*

YesNo
Are you satisfied with your teeth's appearance?*

YesNo
Would you like to keep all of your teeth all of your life?*

YesNo
Please honestly share your expectations regarding your treatment, the doctor, the staff and the office:
#4 MEDICAL HISTORY
Patient Name*
1. Have you been under the care of a medical doctor during the past two years?*

YesNo
If yes, for what
Physician's Name
Physician's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician's Phone

Area CodePhone Number
2. Have you taken any medication during the past two years including appetite suppressants – fen-phen, phentermine or dexfenfluramine or fenfluramine?*

YesNo
3. Are you taking any medication, drugs or pills now?*

YesNo
If yes, what medications?
Including Tagamet (Cimetidine)?*

YesNo
Antacids?*

YesNo
If yes, how often?
4. Do you take anything to help you rest, relax, or sleep?*

YesNo
If yes, please list name and dosage
5. Are you aware of having an allergic (or adverse reaction) to any medication or substance or food?*

YesNo
To Local Anesthetics?*

YesNo
To Penicillin or Antibiotics?*

YesNo
Aspirin?*

YesNo
Codeine, Valium or Sedatives?*

YesNo
Other allergies not listed:
6. Have you been a patient in the hospital during the past five years?*

YesNo
If yes, for what conditions:
7. Indicate which of the following you have had or have at present. Check multiple conditions.
Check the conditions that you have had or have at present*

COVID-19Heart (Surgery, Disease, Attack)Chest PainCongenital Heart DiseaseHeart MurmurHigh Blood PressureMitral Valve ProlapseArtificial Heart ValveHeart PacemakerRheumatic FeverArthritis/RheumatismCortisone MedicineSwollen AnklesStrokeDiet (Special/Restricted)Artificial Joints (hip, knee, etc.)Kidney TroubleUlcersDiabetesThyroid ProblemsGlaucomaContact LensesEmphysemaChronic CoughTuberculosisAsthmaHay FeverLatex SensitivityAllergies or HivesSinus TroubleSore or Enlarged Lymph NodesCancer/TumorsRadiation Therapy/BiopsiesChemotherapyHepatitis A (infectious)Hepatitis B (serum)Venereal DiseaseA.I.D.SH.I.V PositiveCold Sores/Fever BlistersBlood TransfusionHemophiliaSickle Cell DiseaseBruise EasilyLiver DiseaseYellow JaundiceNeurological DisordersEpilepsy or SeizuresFainting or Dizzy SpellsNervous/AnxiousPsychiatric/Psychological CareCosmetic AugmentationNONE OF THE ABOVE
Do you use more than two pillows to sleep?*

YesNo
8. Have you lost or gained more than 10 pounds in the past year?than two pillows to sleep?*

YesNo
Height*
Current Weight*
Do you have or have you had any disease, condition, or problem not listed??*

YesNo
If yes, please list:
Women: Are You:
Pregnant?*

YesNo
Months
Nursing?*

YesNo
Taking birth control pills?*

YesNo
Men: Are You Taking:
Viagara, Cialis or Levitra*

YesNo
Have you ever had a lawsuit with a doctor or dentist?*

YesNo
I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of any change in my health or medication.
Patient/Guardian Signature*

Clear
Sign Here
Date*

MonthDayYear
Date
Should be Empty:

#1 PATIENT REGISTRATION

#2 CONSENT FOR TREATMENT

HIPPA

#3 DENTAL HISTORY

#4 MEDICAL HISTORY