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REGISTRATION AND HISTORY
PATIENT INFORMATION
Last Name
First Name
Middle Name
Date
Cell Phone
Home Phone
Email
Date Of Birth
SSN (Insurance purposes)
Address
City
State
Zip Code
Status (insurance purposes)
Employer/School
Employer/School Phone Number
Whom may we thank for referring you
In case of emergency, who should we contact?
Relationship?
Emergency Contact's Phone
Emergency Contact's Alternate Phone
DENTAL INSURANCE INFORMATION
Please fill out to the best of your knowledge
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Attach insurance information using the uploader below
Please be advised, our office only accepts Delta Dental

Premier
 as
In-Network
. Other insurance providers are considered
Out of Network
and will be subject to Out of Network fees. If your insurance information changes, you are responsible for informing our office of the change in order to receive accurate financial estimates.
Please initial to confirm.
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Insurance Card Information
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Insurance Card Information
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Insurance Card Information
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Subscriber Last Name
Subscriber First Name
Subscriber Date of birth
Subscriber SSN
Subscriber Phone
Subscriber's Address is:
Address
City
State
Zip Code
Dental Insurance Company
Subscriber ID #
Group Number
Subscriber Employer
Is patient covered by a secondary insurance?
Subscriber Last Name
Subscriber First Name
Subscriber Date of birth
Subscriber SSN
Subscriber Phone
Subscriber's Address is::
Address
City
State
Zip Code
Dental Insurance Company
Subscriber ID #
Group Number
Subscriber Employer
DENTAL HISTORY
Reason for today's visit
Estimated date of last dental visit
Former Dentist
Phone
Estimated date of last X-rays
Please select if you have/had any of the following:
How often do you floss?
How often do you brush?
MEDICAL HISTORY
Physician's name:
Estimated date of last visit
Do you wear contact lenses?
Have you ever taken any of the group of drugs commonly known as "Fosamax" or "Boniva" (Bisphosphonates)
Gave you taken Viagra, Revatio, Cialis, or Levitra in the past 24 hours?
Please select "Yes" or "no" to indicate if you have/had any of the following:
AIDS/ARC/HIV
Anemia
Arthritis/ Rheumatism
Asthma
Artifical joints
Placement and date of Artificial joints:
Abnormal Bleeding
Blood Disease
Chemotherapy
Cancer
What type of cancer:
Circulatory Problems
Cough; persistent or bloody?
Diabetes
Emphysema/ Bronchitis
Epilepsy/ Seizures
Fainting/ Dizziness
Glaucoma
Headaches/ Migraines
Heart murmur
Heart problems
High blood pressure
Jaundice
Hepatitis
What type of Hepatitis:
Kidney disease
Liver disease
Low blood pressure
Nervous disorders
Radiation treatment
Rashes/hives
Respiratory problems
Rheumatic fever
Sinus problems
Speech difficulties
STD/ herpes
Stroke
Date of stroke:
Swollen feet/ ankles
Swollen glands
Thyroid problems
Tuberculosis
Vision problems
Surgeries:
Transplants:
History of heart attack?
Date of heart attack
History of auto-immune disease?
Auto-immune disorder
Do you take antibiotics prior to dental appointments as indicated by your physician for premedication?
Was it taken today?
What do you take for your premedication?
What condition is it for and who is the physician that prescribed it?
Have you received the COVID-19 vaccine?
Date of vaccine #1
Date of vaccine #2
Most recent booster
Allergies:
Other
Are you taking birth control?
Name of birth control:
Are you currently or is there a chance you could be pregnant?
Estimated Due Date
Please list any other medical conditions we should be aware of:
Please list any other medications and the reason you are taking them:
Patient First Name
Patient Last Name
Date Of Birth
Patient/Legal Guardian Signature
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