Clicky

Register Form

Register form

A quick registration form for patients whishing to have an appointment.

Patient Informations

  • M
  • F

Appointment Informations

Dental Insurance Informations

Do you have dental insurance? (Primary Dental Insurance)
Insurance Company
Name of Policy Holder
Patient ID Number
Relation to Patient
Group Number
Date of Birth

Health Information

Are you in good health?
Are you pregnant (if applicable)?
Have you ever been hospitalized? If yes, please explain.

Are you under the care of a physician for any medical condition within the last 2 yrs?. If yes, please explain.

Have you recently, or are you presently, taking any PRESCRIPTION or NONPRESCRIPTION DRUGS? If yes, please list.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Are you allergic to any medications, foods or latex? If yes, please list.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Do you have an artificial joint of any kind? If yes, please explain.

Are you HIV Positive or have AIDS? If yes, please explain.

Have you ever had surgery? If yes, please list.
1.
2.
3.
4.
5.
6.
7.
8.
Do you smoke or use other forms of tobacco? If yes, please list.
1.
2.
3.
4.
Have you had or currently have any of the following?
Check those that you had and leave empty those that you did not have.