Patient Registration

You may preregister with our office by filling out our secure online Patient Registration Form below. After you have completed the form, please make sure to press the Submit button at the bottom to automatically send us your information. On your first visit to our office, we will have your completed form available for your signature. The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.

If you do not wish to fill out the form online, you may also download a printable version.

Patient Information First Name: Last Name:
DOB: Age:
Sex: Male Female
Marital Status: Married Single Widowed Divorced
Address: City:
State: Zip Code:
Home Phone: Work Phone:
Cell Phone:
SSN: Employer:
Employer Address: Email:

Insurance Information Dental Insurance Company:
ID #: Group #:
Medical Insurance Company:
ID #: Group #:
PolicyHolder Name: Relation To Patient:
DOB: SSN:
Address: City:
State: Zip Code:
Employer: Work Phone:

Spouse/Guardian Information Spouse/Guardian: Spouse Guardian
Name:
DOB: SSN:
Home Phone: Work Phone:
Address: Employer:

Emergency Contact Name: (Someone not living with you)
Phone: Relationship:

Visit Details Why are we seeing you today?
Who are we to thank for sending you to see us today?
First Name: Last Name:

Payment

If you do not have insurance, 100% of fees are due at the time of service. If your account is turned over to collections, you will be responsible for any and all collection and reasonable attorney fees.

Payment Method: Cash Check Credit Card

Referring Doctors Referring Doctor:
City: State:
Referring Dentist:
City: State:

Previous Conditions Diabetes: Yes No Kidney Trouble: Yes No
Venereal Disease: Yes No Rheumatic Fever: Yes No
Jaundice: Yes No A.I.D.S.: Yes No
Heart Murmur: Yes No Hepatitis: Yes No
High/Low Blood Pressure: Yes No Tuberculosis: Yes No
Anemia: Yes No Cancer: Yes No
Heart Trouble: Yes No Bleeding Problems: Yes No
Stroke: Yes No Liver Trouble: Yes No
Epilepsy: Yes No Pregrant (At Present): Yes No
Lung Trouble: Yes No Seizures: Yes No
Radiation Treatment: Yes No Stomach/Colon/Bowel Trouble: Yes No

If yes to cancer, what type:
If pregnant, list due date:
Unusual Reaction to anasthetic: Yes No
If yes, give details:
Previous Hospitalization / Outpatient Surgery: Yes No
If yes, give details & dates:
Do you smoke / use tobacco: Yes No
List any allergies to medications:
Allergic to latex: Yes No
List medications you are currently taking (include birth control):
Do you wear contact lenses: Yes No
If yes, are you wearing them now:
Other Medical Info:

Signature & Agreement

By signing below, you acknowledge and understand that your coverage and/or fees are estimates only. This is not a guarantee of payment and you are solely responsible for your account of any and all charges.
I hereby certify that I have received and / or have been offered a copy of this office's Privacy Policies Notice.

Signature of Patient/Responsible Party:

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