New Patient Registration Form - General Dentistry

Patient Information

• Full Name: _________________ Date: _________________
• Date of Birth: ______________ Social Security #: _______________
• Address: ________________________________________________
• City: _____________ State: _______ ZIP: _________
• Home Phone: _____________ Cell Phone: _____________
• Email: ________________________________________________
• Preferred Contact Method: □ Phone □ Email □ Text

Emergency Contact

• Name: _________________ Relationship: _________________
• Phone: _________________ Alt. Phone: _________________

Medical History

Current Medical Conditions (check all that apply):

□ Heart Disease □ Diabetes □ High Blood Pressure □ Arthritis □ Cancer □ Bleeding Disorders □ Other: _________________

Current Medications

• List all medications: ____________________________________
• Allergies: ____________________________________________

Dental History

• Last Dental Visit: ________________
• Reason for Today's Visit: ________________________________
• Are you experiencing dental pain? □ Yes □ No
• Do your gums bleed when brushing? □ Yes □ No

Insurance Information

• Primary Dental Insurance: _______________________________
• Policy Holder's Name: __________________________________
• Policy Holder's DOB: ___________________________________
• Group #: _________________ ID #: _________________

Consent

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

Signature: _________________ Date: _________________