New Patient Registration

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

Name(Required)

FirstLast

Patient is:(Required)

Responsible Party

Child

Address(Required)

Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountry

Birth Date(Required)

MM slash DD slash YYYY

Sex(Required)

Male

Female

Other

Marital Status(Required)

Single

Married

Divorced

SSN(Required)

Email(Required)

Phone(Required)

Untitled

First Choice

Second Choice

Third Choice

How did you hear about us?(Required)

Employer Name(Required)

Employer Phone(Required)

Emergency Contact(Required)

Relation(Required)

Phone(Required)

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.(Required)

Allow

DO NOT Allow

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

Yes

No

Name

FirstLast

Relation to Patient

Parent

Child

Guardian

Address

Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountry

Home Phone

Cell Phone

Other Phone

Birth Date

MM slash DD slash YYYY

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

MM slash DD slash YYYY

SSN or ID#

DOB

MM slash DD slash YYYY

SSN or ID#

Relationship to Patient

Relationship to Patient

Dental History

Reason for today's visit(Required)

Date of last dental care(Required)

Former dentist(Required)

Date of last dental x-rays(Required)

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

Bad breath

Grinding 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(Required)

How often do you brush(Required)

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-medication 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, etc

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

None

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 (please list below)

If your allergies are not listed above please list below:

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.(Required)

Click yes if you agree.

Patient name

Date

MM slash DD slash YYYY

Signature

Relationship to patient

Signature(Required)

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