NEW PATIENT REGISTRATION

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Patient Information

Patient's First Name(*)
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Patient's Last Name(*)
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Up to 10MB, jpg, png, gif, bmp, tiff

Attach a photo, so we recognize you on your visit. (Internal use only)

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Birthdate (MM/DD/YYYY)(*)
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Sex(*)
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Marital Status(*)
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Social Security Number
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Address(*)
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Apt #
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City(*)
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State(*)
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Zip Code(*)
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Home Phone
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Mobile Phone
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Email Address(*)
Please specify your email address.
School Name (full-time student)
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Employment Information

Employer's Name
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Occupation
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Work Phone
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Relationship to Patient:(*)
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First Name(*)
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Last Name(*)
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Does this person & patient reside in the same household?
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Birthdate (MM/DD/YYYY)
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Sex
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Social Security Number
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Address
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Apt #
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City
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State
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Zip Code
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Home Phone
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Work Phone
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Dental Insurance

Are you currently covered by Dental Insurance?(*)
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Office Policy

In order to better serve you in the most consistent, efficient and transparent way possible, we have established the following office policies.
Please place your initials by each to indicate that you have read and understood them.
Initials(*)
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Payment and/or copayment is required in full at the time services are rendered. If you have dental insurance coverage, please be advised that the co-payment requested for services rendered is only an estimate based on information that was given to us by your insurance company.

Initials(*)
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If you have any questions about your insurance coverage, please let us answer them before treatment begins. Otherwise, the assumption will be that you are familiar with your dental plan coverage and limitations.

Initials(*)
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The Doctor and/or hygienist have reserved your appointment time slot ESPECIALLY for you. A minimum of 24 hour notice is required for all appointment changes or cancellation in order to avoid a $50 broken appointment fee.

Initials(*)
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There will be a $35 fee for each returned (bad) check that we receive.

Initials(*)
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Past due accounts (having a balance for more than 60 days) will be charged a 1.5% monthly interest rate until the account balance is reconciled. Delinquent accounts (unpaid balances of more than 90 days) will be transferred directly to a collections agency.

Do you have or have you ever been treated for any of the following:

Choose YES if you do have the condition.

Any heart problems
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Heart attack
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Angina
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Bypass
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Pacemaker
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Stroke
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High blood pressure
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Low blood pressure
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Heart murmur
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DO YOU NEED TO PRE-MED
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Mitral valve prolaspe
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Heart valve defect
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Heart valve replacement
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Rheumatic fever
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Artificial joint
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Any bleeding disorder
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Anemia
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Hemophilia
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Sickle cell trait
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Blood transfusion
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Sexual transmitted disease
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Other infectious disease
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Chemotherapy/radiation
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Are you pregnant?
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Other growths
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Cancer/Tumor
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HIV/AIDS
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Do you smoke?
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Lung/breathing problems
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Asthma
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Bronchitis
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Emphysema
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Tuberculosis
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Sinus trouble
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Diabetes
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Difficulty healing
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Liver problems/dysfunction
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Adrenal/pituitary problem
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Hepatitis/jaundice
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Kidney problems/dysfunction
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Stomach trouble/ulcer
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Alcoholism
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Drug abuse
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Nervous/mental disorder
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Epilepsy or seizures
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Thyroid problems
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Allergic to Erythromycin
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Allergic to Codeine
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Reaction to local Anesthesia
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Allergic to Penicillin
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Allergic to Sulfa
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Allergic to Aspirin
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Other Allergies?
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If yes, please list:
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Do you have any current health problems not noted above?
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If yes, please explain:
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Are you currently being treated by a physician?
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If yes, please explain:
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Physician's Full Name
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Physician's Phone
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Are you presently taking any medications or pills?
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If yes, please list below.
Drug:
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Purpose:
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Drug:
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Purpose:
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Drug:
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Purpose:
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Emergency Contact Information

Emergency Contact Name(*)
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Emergency Contact Phone(*)
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Emergency Contact Relation to Patient(*)
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Dental History

Purpose of today's visit: (*)
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If Other
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Are you aware of a problem?
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When was your last dental visit?
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When were x-rays last taken?
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Previous dentist's name and address?
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When was the last time your teeth were cleaned?
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Have you ever had an adverse/bad dental experience?
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If yes, please explain:
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Do you think you have any decay?
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Do your gums bleed easily?
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Do you suffer from bad breath?
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Do you have jaw/joint pain?
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Are you unhappy w/ appearance of your teeth?
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Are your teeth sensitive?
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Have you had gum surgery?
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Do you clench or grind your teeth?
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Interested in permanent replacement of teeth?
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Would you like "whiter" teeth?
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Do you have any concerns
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Do you snore?
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If yes, would you consider treatment?
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How did you hear about our practice?

This information will help us a lot.(*)
Please make a selection
Name of the person
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Please give some details
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When you are finished filling out the registration form, click on antispam and then click the submit button, and we will instantly receive it.

North Potomac Smiles

15200 Shady Grove Rd,
Suite 408
Rockville, MD 20850

 Office Hours
Monday-Thursday: 8:30 am - 5:00 pm
Friday: 7:30 am - 3:00 pm
Saturday & Sunday: Closed

 (301) 926-4408

 

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