Patient Registration Form Patient Information Salutation Mr.Mrs.Ms.Dr. First Name Last Name Registering for child? YesNo Parent or Guardian Person responsible for account Other Parental Consent Required Mother's Name Mother's Cell Number Mother's Work Number Father's Name Father's Cell Number Father's Work Number Date of Birth MonthJanFebMarAprMayJuneJulyAugSepOctNovDecDay12345678910111213141516171819202122232425262728293031Year2017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903190219011900 Contact Information Email Home Phone Cell Phone Work Phone Address City Postal Code In case of emergency, please notify: Name Relation Home Phone Cell Phone Work Phone Contact Options I prefer appointment reminders by PhoneSMSEmail Whom may we thank for referring you? Are any other members of your family patients at our practice? YesNo If yes, whom? Insurance Information Please complete the following if you have dental insurance Name of insured/subscriber Date of Birth MonthJanFebMarAprMayJuneJulyAugSepOctNovDecDay12345678910111213141516171819202122232425262728293031Year2017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903190219011900 Patient's relationship to subscriber SelfSpouseChildOther Place 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/Maybe If so, why When was your last medical check-up? MonthJanFebMarAprMayJuneJulyAugSepOctNovDecDay12345678910111213141516171819202122232425262728293031Year20172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950 Has there been any change in your general health in the past year? YesNoNot Sure/Maybe If yes, why Are you taking any prescription, non-prescription medications, or herbal supplements? YesNoNot Sure/Maybe If yes, please list below and include dosage Do you have any allergies? YesNoNot Sure/Maybe If yes, please list in the categories below. Medications Latex/Rubber Products Other (e.g. hayfever, foods etc.) Have you ever had a peculiar or adverse reaction to any medicines or injections? YesNoNot Sure/Maybe If yes, please list below and describe Do you have or ever had asthma? YesNoNot Sure/Maybe Do you have or ever had any heart or blood pressure problems? YesNoNot Sure/Maybe Have you ever/do you have 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/Maybe Do you have a prosthetic or artificial joint? YesNoNot Sure/Maybe Do you have any conditions which may affect your immune system? (i.e. Leukemia, AIDS, HIV Infection, Radiotherapy, Chemotherapy) YesNoNot Sure/Maybe Have you ever had hepatitis, jaundice, or liver disease? YesNoNot Sure/Maybe Do you have a bleeding problem or bleeding disorder? YesNoNot Sure/Maybe Have you ever been hospitalized for any illnesses or operations? YesNoNot Sure/Maybe If yes, please explain. Do you have, or have ever had any of the following? Please check. Are there any conditions/diseases not listed that you have or have had? YesNoNot Sure/Maybe If yes, please explain. Are there any diseases/medical problems that run in your family (eg-diabetes, cancer, heart disease)? YesNoNot Sure/Maybe If yes, please explain. Do you smoke or chew tobacco products? YesNoNot Sure/Maybe Are you nervous during dental treatment? YesNoNot Sure/Maybe For women only: Are you breastfeeding or pregnant? YesNoNot Sure/Maybe If pregnant, what is your expected delivery date? MonthJanFebMarAprMayJuneJulyAugSepOctNovDecDay12345678910111213141516171819202122232425262728293031Year20172018 Dental History Do you have any specific dental concerns? Please list When was your last dental appointment? MonthJanFebMarAprMayJuneJulyAugSepOctNovDecDay12345678910111213141516171819202122232425262728293031Year20172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950 How often do you see the dentist? Not ApplicableEvery 3 monthsEvery 4 monthsEvery 6 monthsOnly when something is bothering me Is there anything about the appearance of your teeth that you would like to change? Have you ever whitened (bleached) your teeth? Have you felt 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 Brush Floss & Smile’s emails with related information and updates.