New Patient Registration

Kyle Harmon, DDS.| (801) 544-9777 | 836 S Angel St. Suite 100 Layton, UT 84041

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New Patient Registration

Please fill out the following information prior to arriving at our office.

First Name *

Last Name *

Patient is: *

Responsible Party
Child

Address *

City *

State *

Zip *

Birth Date *

Sex *

Male
Female
Other

Marital Status *

Single
Married
Divorced

SSN *

Email Address *

Phone Number *

How did you hear about us? *

Employer Name *

Employer Phone *

Emergency Contact *

Relation *

Phone Number *

I authorize the use of my mobile phone number, listed on this form, to receive phone calls and/or text messages regarding billing and scheduling. I agree to update Central Davis Dental if my mobile number changes. *

Allow
DO NOT Allow

Responsible Party (Guardian of patient, if patient is under 18 years old) Currently a patient in our office *

Yes
No

First Name

Last Name

Relation to Patient

Parent
Child
Guardian

Address

City

State

Zip

Home Phone

Cell Phone

Other Phone

Birth Date

Sex

Male
Female
Other

Marital Status

Single
Married
Divorced

SSN

Email Address

Employer Name

Employer Phone

Insurance Information

Primary Insurance

Secondary Insurance

Insurance Address

Insurance Phone

Name of Subscriber

DOB

SSN or ID#

DOB

SSN or ID#

Relationship to Patient

Dental History

Reason for today's visit *

Date of last dental care *

Former dentist *

Date of last dental x-rays *

Check the boxes If you have or have had problems with any of the following:

Bad breath
Grindlng teeth
Sensitivity to hot
Loose fillings
Loose teeth
Sensitivity to cold
Clicking/popping jaw
Periodontal treatment
Sensitivity to sweets
Food collecting between teeth
Bleeding gums
Sensitivity to biting

How often do you floss *

How often do you brush *

Medical History

Physician's name

Physician's phone

Date of last visit

Are you currently, or recently, been taking Bisphosphonate medications?

Yes
No

Have you ever had any serious Illnesses or operations?

Yes
No

If yes, describe

Do you require antibiotic pre-medlcatlon for heart condition, artificial valve, or artificial joint?

Yes
No

Are you pregnant?

Yes
No

Due:

Nursing?

Yes
No

Taking birth control pills?

Yes
No

History:

Anemia
Arthritis
Artificial Heart Valves
Artificial Joints, Pins, ect
Asthma
Back Problems
Bleeding Abnormally
Blood Disease
Cancer
Chemical Dependency
Chemotherapy
Circulatory Problems
Congenital Heart Lesions
Cortisone Treatments
Cough, Persistent
Cough up Blood
Diabetes
Epilepsy
Fainting
Glaucoma
Heart Murmur
Heart Problems
Hemophilia
Hepatitis A, B or C
Hernia Repair
High Blood Pressure
HIV/AIDS
Jaw Pain/TMJ
Kidney Disease
Liver Disease
Mitral Valve Prolapse
Pacemaker
Radiation Treatment
Respiratory Disease
Rheumatic Fever
Rheumatism
Scarlet Fever
Shortness of Breath
Skin Rash
Stroke
Swelling of Feet or Ankles
Thyroid Problems
Tobacco Habit
Tonsillitis
Tuberculosis
Ulcer
Venereal Disease
Other

List of current medications you are taking:

Are you currently on a pain contract with your physician?

Yes
No

Have you ever undergone psychiatric care?

Yes
No

Allergies:

Aspirin
Barbiturates (Sleeping pills)
Clindamycin
Erythromycin
Iodine
Codeine
Latex
Local Anesthetic
Penicillin
Sulfa
None
Other

To the best of my knowledge, the above Information Is complete and correct. I understand that It Is my responsibility to Inform my doctor if I, or my minor child, ever have a change in health. *

Click yes if you agree.

Patient name

Date

Signature (parent or guardian If minor)

Relationship to patient