Patient Registration Form - American Dental Association

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Patient Registration Form
American Dental Association
Email:
Today’s Date:
o
o
o
o
o
Referred by:
Preferred Name:
Miss
Mr.
Mrs.
Ms.
Dr.
Name:
Home Phone:
Cell Phone:
include area code
include area code
(
)
(
)
Last
First
Middle
Address:
City:
State:
Zip:
Mailing address
SS#:
Date of Birth:
Sex: M
F
Employer:
Business Phone:
include area code
(
)
Emergency Contact:
Relationship:
Home Phone:
Cell Phone:
include area code
include area code
(
)
(
)
College Student Status:
o
Full Time
o
Part Time
Please provide school info:
School Name:_______________________________________
o
o
o
Employment Status:
Full Time
Part Time
Retired
Address:_______________________________________
o
o
o
o
o
Marital Status:
Married
Single
Divorced
Separated
Widowed
Address 2:_______________________________________
Pref. Pharmacy:
Phone: (
)
City, State, Zip:_______________________________________
Dental Insurance Information
Primary Insurance Information
Name of Insured: ___________________________________________________
Relationship to Patient:
o
Self
o
Spouse
o
Child
o
Other
Insured Soc. Sec.: __________________________________________________
Insured Birth Date: _____________________________________________
Employer:_____________________________________________________
Ins. Company: ________________________________________________
Address:_____________________________________________________
Address: ________________________________________________
Address 2:_____________________________________________________
Address 2: ________________________________________________
City, State, Zip:_____________________________________________________
City, State, Zip: ________________________________________________
ID#: _____________________________
Gr#: ___________________________
Secondary Insurance Information
o
o
o
o
Name of Insured: ___________________________________________________
Relationship to Patient:
Self
Spouse
Child
Other
Insured Soc. Sec.: __________________________________________________
Insured Birth Date: _____________________________________________
Employer:_____________________________________________________
Ins. Company: ________________________________________________
Address:_____________________________________________________
Address: ________________________________________________
Address 2:_____________________________________________________
Address 2: ________________________________________________
City, State, Zip:_____________________________________________________
City, State, Zip: ________________________________________________
ID#: _____________________________
Gr#: ___________________________
Dental Information
For the following questions, mark (X) your responses to the following questions.
Yes No DK
Yes No DK
Do your gums bleed when you brush or floss? . . . . . . . . . .
o o o
Do you have earaches or neck pains? . . . . . . . . . . . . . . . .
o o o
Are your teeth sensitive to cold, hot, sweets or pressure? .
o o o
Do you have any clicking, popping or discomfort in the jaw?
o o o
Is your mouth dry? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
o o o
Do you brux or grind your teeth? . . . . . . . . . . . . . . . . . . . .
o o o
Have you had any periodontal (gum) treatments? . . . . . . .
o o o
Do you have sores or ulcers in your mouth? . . . . . . . . . . . .
o o o
o o o
o o o
Have you ever had orthodontic (braces) treatments? . . . . .
Do you wear dentures or partials? . . . . . . . . . . . . . . . . . . .
o o o
Have you had any problems associated with previous
Do you participate in active recreational activities? . . . . . .
o o o
o o o
dental treatment? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Have you ever had a serious injury to your head or mouth?
o o o
Is your home water supply fluoridated? . . . . . . . . . . . . . . .
Date of your last dental exam:
o o o
Do you drink bottled or filtered water? . . . . . . . . . . . . . . . .
What was done at that time?
If yes, how often? Circle one: DAILY / WEEKLY / OCCASIONALLY
o o o
Are you currently experiencing dental pain or discomfort?
Date of last dental x-rays:
What is the reason for your dental visit today?
How do you feel about your smile?
over

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