Adult Patient Information

Adult Registration Form - Dental
* required field

Patient Information






Primary Phone Number *
Secondary Phone Number



Spouse/Emergency Contact Information

Marital Status




How did you hear about our Practice?

Insurance Information






















Dental History



Do you like your smile?
Have you ever been told you have periodontal(gum) disease?
Have you ever received home care instructions?

Have you ever had an injury to (select all that apply):
Do you currently or have you ever had any of the following symptoms or conditions?
Have your tonsils or adenoids been removed?
Do you have speech problems?

Medical History

Are you currently being treated by a physician?



Are you allergic to or have had any reactions to any medications?
If yes, please check all that apply










Are you currently taking any prescription or over-the-counter medications?
Have you ever been hospitalized for any surgical operation or serious illness?

Have you ever had a blood transfusion?
Have you ever taken any of the group of drugs collectively referred to as fen-phen? These include combinations of Ionimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?
Have you ever had bisphosphonate therapy?
Have you ever taken oral bisphosphonate?
If yes, which kind?



Have you ever had IV therapy for any of the following?
If yes, which kind?


Have you ever had any form of cancer?

Do you use controlled substances?
Are you wearing contact lenses?
Check if you have or have ever had any of the following:

(Women)





Authorization

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 health. It is my responsibility to inform the dental office of any changes in my medical status.I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am financially responsible for any amount whether or not covered by insurance. I agree to pay all costs of collections including legal fees. I authorize the use of my signature on all insurance submissions.




Security Measure