Adult Patient Form

Adult Registration Form -

Patient Information

Phone Type
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Spouse / Partner Information

Marital Status:
Phone Type:
Phone Type:

Emergency Contact Information

Insurance Information

Primary Insurance

Secondary Insurance

Dental History

Xrays taken?
Do you have dental anxiety?
How did you hear about our practice?
Have your tonsils or adenoids been removed?
Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)?
Do you have any missing or extra permanent teeth?
Wisdom teeth removed?
Have you ever had an injury to (select all that apply):
Do you have speech problems?
Do your gums bleed?
Do you smoke?
Do you experience dry mouth?
Do you like your smile?
Do you currently or have you ever had any of the following habits(check all that apply):
Bad breath?
Sensitive to hot, cold, or sweets?
Any broken fillings or teeth?
Family history of gum disease?
Have you ever had a deep cleaning for periodontal/gum disease in the past?
Did you complete treatment or are you in maintenance phase?
How often do you brush?
Do you use electric or manual brush?
How often do you floss?

Medical History

Are you currently being treated by a physician?
Do you have any allergies/sensitivities to medications, Sulfa, dyes, milk, dairy, metals or latex?
Are you currently taking any prescription or over-the-counter medications?
Have you ever taken any of the group of drugs collectively referred to as fen-phen? These include combinations of lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?
Have you ever taken any medications for bone density/osteoporosis the drug class bisphosphonates? Reclast, Fosamax, Boniva, Zometa, Actonel, Or Atelvia.
Have you ever had a blood transfusion?
(Women) Are you pregnant?
Taking birth control pills?
History of an eating disorder?
Check if you have ever had any of the following:


I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status.

I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.

I understand that where appropriate, credit bureau reports may be obtained.

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