Patient Information

Online Patient Registration Form

You may preregister with our office by filling out our online Patient Registration Form. After you have completed the form, please make sure to press the Submit button at the bottom to automatically send us your information.

Patient Information
Mr     Mrs     Dr     Ms
Sex:     Male     Female
Marital Status:     Single     Married     Divorced     Widowed
Who will be responsible for account?     Self     Spouse     Father     Mother     Other
Emergency Contact
Home Address
Referral
Employment History or School
Primary Dental Insurance Company
Primary Medical Insurance Company
Medical History
Have you had any illness, operation or been hospitalized in the past five years?
Is there any condition concerning your health or your family’s anesthetic history that the doctor should be told?
Do you have a prosthetic joint or valve?     Yes     No
Do you smoke or chew tobacco?     Yes     No
Do you consume alcoholic beverages?     Yes     No
Please list all medications, drugs, pills, or herbs you are currently taking:
Please list all allergies you have including Penicillin, Aspirin and Eggs or Egg products:
Women:   Is there a possibility that you may be pregnant?     Yes     No
Women:   Are you nursing?     Yes     No
Have you had or do you currently have...
Prosthetic Heart Valve     Yes     No
Congenital Heart Disease     Yes     No
Previous Endocarditis     Yes     No
High Blood Pressure     Yes     No
Cardiac Transplant     Yes     No
Chest Pain, Angina     Yes     No
Heart Attack     Yes     No
Irregular Heart Beat     Yes     No
Cardiac Pacemaker     Yes     No
Heart Surgery     Yes     No
Bronchitis, Chronic Cough     Yes     No
Asthma     Yes     No
Hayfever / Sinus Problems     Yes     No
Tuberculosis     Yes     No
Emphysema     Yes     No
Difficulty Breathing     Yes     No
Blood Transfusion     Yes     No
Blood Disorder such as Anemia     Yes     No
Bruise Easily     Yes     No
Abnormal Bleeding Tendency     Yes     No
Jaundice, Hepatitis or Liver Disease     Yes     No
Infectious Mononucleosis     Yes     No
Stroke     Yes     No
Thyroid Trouble     Yes     No
Diabetes     Yes     No
Low Blood Sugar     Yes     No
Kidney Trouble     Yes     No
Are you on Dialysis     Yes     No
Swollen ankles, Arthritis or Joint Disease     Yes     No
Stomach Ulcer     Yes     No
Contagious Disease     Yes     No
Sexually Transmitted Disease     Yes     No
Problems of the Immune System     Yes     No
A tumor or Growth     Yes     No
Mental Health Problems     Yes     No
Are you wearing a removable dental appliance     Yes     No
Are you on a diet     Yes     No
Are you taking Bisphosphonates (Fosamax, etc.)     Yes     No
Contact Lenses     Yes     No
Eye Disease / Glaucoma     Yes     No
Radiation Treatment / Chemotherapy     Yes     No
Pain and Clicking of the Jaws     Yes     No
Malignant Hyperthermia     Yes     No
Convulsions / Epilepsy     Yes     No

How we can help...

We offer a wide range of procedures to help you get the perfect smile.