Kyle Harmon, DDS.|
(801) 544-9777
|
836 S Angel St. Suite 100 Layton, UT 84041
Main Menu
Home
Family Care
Pediatrics ages 0-12
Teens ages 13-19
Adults ages 20-59
Simpli 5
Patient Reward Programs
Meet Our Staff
Request Appt.
Feedback/Reviews
Patient Resources
New Patient Registration
New Patient Forms
Procedures
Types of Insurance
Where Is CDD?
New Patient Registration
Home
New Patient Registration
Please fill out the following information prior to arriving at our office.
Please enable JavaScript in your browser to complete this form.
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 Address
Insurance Phone
Insurance Phone
Name of Subscriber
Name of Subscriber
DOB
SSN or ID#
DOB
SSN or ID#
Relationship to Patient
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
Submit