Patient Registration Form Patient Information *All fields requiredPlease choose your location*--please select--LoxahatcheeBelle GladeSalutation*Mr.Mrs.Ms.Dr.First Name*Last Name*Date of Birth* Date Format: MM slash DD slash YYYY Registering for a child?*YesNoPerson responsible for account*Other parental consent required*YesNoMother’s name*Business Tel*Father’s name*Business Tel*Contact InformationEmail* Home Phone*Cell Phone*Work Phone*Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Code In case of emergency, please notify:Name*Relation*Home Phone*Cell Phone*Work Phone*Contact OptionsI prefer appointment reminders by*PhoneSMS (TEXT)EmailWhom may we thank for referring you?*Are any other members of your family patients at our practice?*YesNoPlease list all family members*Insurance Information*Yes, insurance applies to meNo, insurance does not apply to mePlease complete the following if you have dental insuranceName of insured/subscriber*Date of Birth* Date Format: MM slash DD slash YYYY Patient's relationship to subscriber*SelfSpouseChildPlace of Employment*Insurance Company*Policy/Group #*Certificate/ID #*I authorize release to my dental benefits plan administrator information contained in claims and/or predeterminations* Yes Medical History The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by Doctor/Patient confidentiality. The Dentist will review the questions and explain any that you do not understand. Please complete the entire form.Are you being treated for any medical condition at the present or any time within the past year?*YesNoNot Sure/MaybeWhen was your last medical checkup?* Date Format: MM slash DD slash YYYY Has there been any change in your general health in the past year?*YesNoNot Sure/MaybePlease Specify*Are you taking any prescription, non-prescription medications, or herbal supplements?*YesNoNot Sure/MaybePlease list and provide dosages. If there is insufficient room, please bring a written list of all your medications to your first appointment.Do you have any allergies?*YesNoNot Sure/Maybe--select--*MedicationsLatex/Rubber ProductsOther (e.g hayfever, foods, etc)Have you ever had a peculiar or adverse reaction to any medicines or injections?*YesNoNot Sure/MaybePlease list below with approximate dates* Date Format: MM slash DD slash YYYY Do you have or have you ever had asthma?*YesNoNot Sure/MaybeDo you have or have you ever had any heart or blood pressure problems?*YesNoNot Sure/MaybeDo you have or have you ever had an artificial heart valve, infection of the heart (i.e. #infective endocarditis), a heart condition from birth (i.e. congenital heart disease), or a heart transplant?*YesNoNot Sure/MaybeDo you have a prosthetic or artificial joint?*YesNoNot Sure/MaybeDo you have any conditions which may affect your immune system (i.e. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?*YesNoNot Sure/MaybePlease specify*Have you ever had hepatitis, jaundice, or liver disease?*YesNoNot Sure/MaybeDo you have a bleeding problem or bleeding disorder?*YesNoNot Sure/MaybePlease specify*Have you ever been hospitalized for any illnesses or operations?*YesNoNot Sure/MaybePlease specify*Do you have, or have ever had any of the following? Please check* Select All Chest pain/angina Osteoporosis Medications Mitral Valve Prolapse Shortness of Breath Rheumatic Fever Heart Attack Stroke Cancer Pacemaker Lung Disease Heart Murmur Arthritis Steroid Therapy Diabetes Tuberculosis Drug/Alcohol Dependency Seizures Thyroid Disease Stomach Ulcers Kidney Disease None of the above Are there any conditions/diseases not listed that you have or have had?*YesNoNot Sure/MaybeIf yes, please specify:*Are there any diseases/medical problems that run in your family (e.g. diabetes, cancer, heart disease, etc.)?*YesNoNot Sure/MaybeIf yes, please specify:*Do you smoke or chew tobacco products?*YesNoNot Sure/MaybeAre you nervous during dental treatment?*YesNoNot Sure/MaybeFor women only: Are you pregnant or breastfeeding?*YesNoNot Sure/MaybeWhat is your expected delivery date?* Date Format: MM slash DD slash YYYY Dental HistoryDo you have any specific dental concerns? Please list:*When was your last dental appointment?* Date Format: MM slash DD slash YYYY How often do you see the dentist?*Not ApplicableEvery 3 monthsEvery 4 monthsEvery 6 monthsOnly when something is bothering meIs there anything about the appearance of your teeth that you would like to change?*Have you ever whitened (bleached) your teeth?YesNoNot Sure/MaybeDo you feel uncomfortable or self-conscious about the appearance of your teeth?*Have you been disappointed with the appearance of previous dental work? I agree to receive emails with related information and updates. This iframe contains the logic required to handle Ajax powered Gravity Forms.
