Periodontal Practice New Patient Registration Form

Patient Information

• Full Name: _________________ Date: _________
• Date of Birth: _________ Age: _____ Gender: _____
• Address: _________________________________
• City: _____________ State: ____ ZIP: ________
• Phone: (Home) _________ (Cell) _________
• Email: _________________________________
• Emergency Contact: _________ Phone: _________

Dental Insurance Information

• Primary Insurance Company: _________________
• Policy Holder's Name: _____________________
• Policy Holder's DOB: ______________________
• Policy/Group Number: _____________________

Medical History

Please check if you have or have had any of the following:

• Heart Disease
• High Blood Pressure
• Diabetes
• Bleeding Disorders
• Joint Replacement
• Osteoporosis

Current Medications:

1. _________________ Dosage: _________
2. _________________ Dosage: _________
3. _________________ Dosage: _________

Dental History

• Last Dental Visit: _________
• Reason for Today's Visit: _________________
• Are your gums bleeding? □ Yes □ No
• Do you experience tooth sensitivity? □ Yes □ No
• Have you had periodontal treatment before? □ Yes □ No

Authorization

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

Signature: _________________ Date: _________