NEW PATIENT REGISTRATION 128 bit SSL encryption Patient Information Patient's First Name(*) Invalid Input Patient's Last Name(*) Invalid Input Up to 10MB, jpg, png, gif, bmp, tiff Attach a photo, so we recognize you on your visit. (Internal use only) Invalid Input Birthdate (MM/DD/YYYY)(*) Invalid Input Sex(*) Please SelectFemaleMale Invalid Input Marital Status(*) Please SelectSingleMarriedDivorced Invalid Input Social Security Number - - Invalid InputInvalid InputInvalid Input Address(*) Invalid Input Apt # Invalid Input City(*) Invalid Input State(*) Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Invalid Input Zip Code(*) Invalid Input Home Phone - - Invalid InputInvalid InputInvalid Input Mobile Phone - - Invalid InputInvalid InputInvalid Input Email Address(*) Please specify your email address. School Name (full-time student) Invalid Input Employment Information Employer's Name Invalid Input Occupation Invalid Input Work Phone - - Invalid InputInvalid InputInvalid Input Person responsible for account Relationship to Patient:(*) SelfSpouseParent/GuardianInvalid Input First Name(*) Invalid Input Last Name(*) Invalid Input Does this person & patient reside in the same household? Please SelectYesNoInvalid Input Birthdate (MM/DD/YYYY) Invalid Input Sex Please SelectFemaleMale Invalid Input Social Security Number - - Invalid InputInvalid InputInvalid Input Address Invalid Input Apt # Invalid Input City Invalid Input State Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Invalid Input Zip Code Invalid Input Home Phone - - Invalid InputInvalid InputInvalid Input Work Phone - - Invalid InputInvalid InputInvalid Input Dental Insurance Are you currently covered by Dental Insurance?(*) Please SelectYesNoInvalid Input 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(*) Invalid Input 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(*) Invalid Input 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(*) Invalid Input 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(*) Invalid Input There will be a $35 fee for each returned (bad) check that we receive. Initials(*) Invalid Input 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 NoYes Invalid Input Heart attack NoYes Invalid Input Angina NoYes Invalid Input Bypass NoYes Invalid Input Pacemaker NoYes Invalid Input Stroke NoYes Invalid Input High blood pressure NoYes Invalid Input Low blood pressure NoYes Invalid Input Heart murmur NoYes Invalid Input DO YOU NEED TO PRE-MED NoYes Invalid Input Mitral valve prolaspe NoYes Invalid Input Heart valve defect NoYes Invalid Input Heart valve replacement NoYes Invalid Input Rheumatic fever NoYes Invalid Input Artificial joint NoYes Invalid Input Any bleeding disorder NoYes Invalid Input Anemia NoYes Invalid Input Hemophilia NoYes Invalid Input Sickle cell trait NoYes Invalid Input Blood transfusion NoYes Invalid Input Sexual transmitted disease NoYes Invalid Input Other infectious disease NoYes Invalid Input Chemotherapy/radiation NoYes Invalid Input Are you pregnant? NoYes Invalid Input Other growths NoYes Invalid Input Cancer/Tumor NoYes Invalid Input HIV/AIDS NoYes Invalid Input Do you smoke? NoYes Invalid Input Lung/breathing problems NoYes Invalid Input Asthma NoYes Invalid Input Bronchitis NoYes Invalid Input Emphysema NoYes Invalid Input Tuberculosis NoYes Invalid Input Sinus trouble NoYes Invalid Input Diabetes NoYes Invalid Input Difficulty healing NoYes Invalid Input Liver problems/dysfunction NoYes Invalid Input Adrenal/pituitary problem NoYes Invalid Input Hepatitis/jaundice NoYes Invalid Input Kidney problems/dysfunction NoYes Invalid Input Stomach trouble/ulcer NoYes Invalid Input Alcoholism NoYes Invalid Input Drug abuse NoYes Invalid Input Nervous/mental disorder NoYes Invalid Input Epilepsy or seizures NoYes Invalid Input Thyroid problems NoYes Invalid Input Allergic to Erythromycin NoYes Invalid Input Allergic to Codeine NoYes Invalid Input Reaction to local Anesthesia NoYes Invalid Input Allergic to Penicillin NoYes Invalid Input Allergic to Sulfa NoYes Invalid Input Allergic to Aspirin NoYes Invalid Input Other Allergies? NoYesInvalid Input If yes, please list: Invalid Input Do you have any current health problems not noted above? NoYesInvalid Input If yes, please explain: Invalid Input Are you currently being treated by a physician? NoYesInvalid Input If yes, please explain: Invalid Input Physician's Full Name Invalid Input Physician's Phone - - Invalid InputInvalid InputInvalid Input Are you presently taking any medications or pills? NoYesInvalid Input If yes, please list below. Drug: Invalid Input Purpose: Invalid Input Drug: Invalid Input Purpose: Invalid Input Drug: Invalid Input Purpose: Invalid Input Emergency Contact Information Emergency Contact Name(*) Invalid Input Emergency Contact Phone(*) - - Invalid InputInvalid InputInvalid Input Emergency Contact Relation to Patient(*) Invalid Input Dental History Purpose of today's visit: (*) Please SelectExam & CleanConsultationPain & DiscomfortOtherInvalid Input If Other Invalid Input Are you aware of a problem? Invalid Input When was your last dental visit? Invalid Input When were x-rays last taken? Invalid Input Previous dentist's name and address? Invalid Input When was the last time your teeth were cleaned? Invalid Input Have you ever had an adverse/bad dental experience? NoYesInvalid Input If yes, please explain: Invalid Input Do you think you have any decay? NoYesInvalid Input Do your gums bleed easily? NoYesInvalid Input Do you suffer from bad breath? NoYesInvalid Input Do you have jaw/joint pain? NoYesInvalid Input Are you unhappy w/ appearance of your teeth? NoYesInvalid Input Are your teeth sensitive? NoYesInvalid Input Have you had gum surgery? NoYesInvalid Input Do you clench or grind your teeth? NoYesInvalid Input Interested in permanent replacement of teeth? NoYesInvalid Input Would you like "whiter" teeth? NoYesInvalid Input Do you have any concerns NoYesInvalid Input Do you snore? NoYesInvalid Input If yes, would you consider treatment? NoYesInvalid Input How did you hear about our practice? This information will help us a lot.(*) Inside referralGoogleYelpFacebookNext-doorInsurance companyOther Please make a selection Name of the person Invalid Input Please give some details Invalid Input Invalid Input When you are finished filling out the registration form, click on antispam and then click the submit button, and we will instantly receive it.