Gentledentistrysgv.com - New Patient Registration

New Patient Registration

Please note that it is important to fill in all the fields before submitting. Thank you.
About you
Title
Name

First NameMiddle NameLast Name
I prefer to be called
Your Birthday

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Sex
Social Security Number
Home Address

Street Address

City

State / ProvincePostal / Zip Code

Apt.#
Email Address
example@example.com
Marital status
Work Phone

Area CodePhone Number
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Driver’s License Number
Employer
How long there ?
Occupation
Employer Address

Address

City

State / ProvincePostal / Zip Code

Apt.#
How did you hear about us?
Whom may we thank for referring you?
Where & when are best times to reach you?
Other family members seen by us
Previous Dentist
Present Dentist
Person responsible for account
Spouse information
His / Her Name

First NameLast Name
Birthday

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Employer
Social Security Number
Driver’s License Number
Telephone Work

Area CodePhone Number
Emergency contact information for patient in case of an emergency
His / Her Name

First NameLast Name
Relationship
Home Telephone

Area CodePhone Number
Work Telephone

Area CodePhone Number
Insurance Information
Primary insurance
Dental Coverage?
Insurance Company Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Group Number (Plan, Local or Policy Number)
Insured’s Name
Relationship
Birthday

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Social Security Number
Insured’s Employer
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have secondary insurance
Dental Coverage?
Insurance Company Name
Address

Street Address

City

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Group Number (Plan, Local or Policy Number)
Insured’s Name
Relationship
Birthday

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Social Security Number
Insured’s Employer
Address

Street Address

City

CityState

Postal / Zip Code
Medical History
Do you have a personal physician?
Physician’s Name
Telephone Home

Area CodePhone Number
Date of last visit

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Your current physical health is
Describe
Are you currently under the care of a physician?
Please Explain
Do you smoke or use tobacco in any other form?
Have you had any metal rods, pins or implants?
Are you taking any prescription or over-the-counter drugs?
Have you ever taken Fosamax, or any other bisphosphonate
Do you wear a cardiac pacemaker, or have you had heart surgery?
Are you required to take any medication before your dental visit?
Are you using a prescribed method of birth control?
Are you pregnant?
Week #
Are you nursing?
Have you ever had any of the following diseases or medical problems
Do you have any serious medical condition(s) that you have ever had?
If "Yes" Please List
Are you allergic to any of the following?
Please List Other Allergic
Do you have any other drugs / Materials that you are allergic to?
If "Yes" Please List
Dental history
Why have you come to the dentist today?
Are you currently in pain?
Do you require antibiotics before dental treatment?
Your current dental health is
Describe
Do you floss daily?
Type of bristles on your toothbrush?
Brush Daily?
Have you ever had gum treatment?
Do your gums ever bleed?
Ever Itch?
Have you ever had periodontal disease?
Have you ever had a serious/difficult problem associated with any previous dental work?
Describe
Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ/TMD)?
Are your teeth sensitive to
Do you have Anything else?
Describe
Do you have any loose teeth?
Do you still have wisdom teeth?
Are you happy with the way your smile looks?
If not, what would you change?
Whiter Teeth?
Would you like a fresher breath?
The information and health history and preceding answers are true and correct to the best of my knowledge. I authorize and give consent to perform dental services agreed between doctor and patient and/or guardian to be necessary or advisable, including the use of local anesthesia and other medications as indicated. I agree that, regardless of insurance coverage, I am responsible for payment for services rendered. If I ever have any changes in my health or if my medication change I will, without fail, inform the doctor at my next appointment.
Signature
Patients Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: