Adult Patient Information

Adult Registration Form - Dental
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Patient Information





Primary Phone Number
Secondary Phone Number



Spouse/Emergency Contact Information

Marital Status









Insurance Information


























Dental History

How did you hear about our Practice?
Have your tonsils or adenoids been removed?
Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)?
Do you have any missing or extra permanent teeth?
Have you ever had an injury to (select all that apply):
Do you have speech problems?
Do your gums bleed?
Do you smoke?
Do you like your smile?
Do you currently or have you ever had any of the following habits?

Medical History

Are you currently being treated by a physician?



Do you have any allergies/sensitivities to medications or latex?
Are you currently taking any prescription or over-the-counter medications?
Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of Ionimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?
Have you had any serious illnesses or operations? If yes, describe:
Have you ever had a blood transfusion?
(Women)




Check if you have or have ever had any of the following:

Broken Appointment Policy

Our office has set many goals, and one of our main goals is to be more responsive to your scheduling needs. We value our patients' time and expect the same in return. One area of scheduling that causes us concern is a Broken Appointment. A broken appointment is defined as not showing up to a scheduled appointment, a 'late cancellation' (cancelling within 24 hours of your appointment), or being 10 minutes tardy. In order to schedule properly and minimize the amount of time between appointment dates, we ask that all our patients keep their appointment times. We call, text, and/or email a week prior to your appointment and the day of to remind you. We ask that you call or text us back to confirm your appointment. We have found that this helps reinforce your ability to remember that you have an appointment. Also, with proper notice, we are able to schedule patients on our waiting list into the cancelled appointment. Our Broken Appointment policy is as follows: First offense: you will be reminded of our policySecond offense: you will be charged as follows:25% of total fee for major procedures (crowns, bridges, root canals, implants ect.)50% of total fee for basic procedures (cleanings, fillings, impressions, denture ect.) 3. Third Offense: Dismissal from the practice We understand that unforeseen circumstances and emergencies may arise. When these situations occur, we ask that you contact our office as soon as you are able. We will review the occurrence and decide whether a broken appointment is warranted. We thank you in advance for your continued commitment to the quality of care we provide and we look forward to working together in the coming years.

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Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.




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