Endodontic Care New Patient Registration Form

Patient Information

• Full Name: _________________ Date: _________________
• Date of Birth: ______________ SSN: _________________
• Address: ________________________________________
• Phone: (Home) ____________ (Cell) _________________
• Email: _________________________________________
• Emergency Contact: _____________ Phone: ___________
• Referring Dentist: _______________________________

Insurance Information

• Primary Insurance: _______________________________
• Policy Holder Name: _____________________________
• Policy Number: _________________________________
• Group Number: _________________________________

Medical History

Please check all that apply:

• Heart Disease/Murmur
• High Blood Pressure
• Diabetes
• Bleeding Disorders
• Artificial Joints/Valves
• Osteoporosis
• Cancer/Chemotherapy

Current Medications:

Allergies:

• Latex
• Penicillin
• Local Anesthetics
• Other: ____________________________________

Dental History

• Reason for Visit: _______________________________
• Pain Level (1-10): _____
• Duration of Symptoms: __________________________

Consent

I hereby certify that the information provided is accurate to the best of my knowledge.

Signature: _________________ Date: ________________

Office Use Only

• BP: / Pulse: ____ SpO2: ____
• Notes: _______________________________________