New Patient Registration

Please note that it is important to fill in all the fields before submitting. Thank you.
Print blank form to fill by hand

About You
Title : Mr Mrs Ms Dr
Patient Name :
Last Name*
 First Name*
 Middle Name
Prefer to be called : Sex : Male Female Age:
Patient's SSN :
Patient's Birthday :
Home Address:*
City
State
Zip
Apt#
Home Phone:* ()--
Work Phone: ()---
Cell Phone : ()--
E-mail:*
Do you have Dental Insurance? Yes No
Marital Status: Single Married Divorced/Separated Widowed
Employer:
Subscriber :
Insurance Company :
Subscriber's SSN :
Subscriber's Birthday :
Where & when are best times to reach you?
How did you hear about us?
Whom may we thank for this referral?
Other family members seen by us:
Previous dentist:
Who is financially responsible for this account?
Nearest Relative Not Living with You
His/Her Parson: Relationship:
Home Phone: ()--
Work Phone: ()---

Medical History
Do you have a personal physician? Yes No
Physician’s Name:
Telephone Home: () - -
Date of last visit:
Your current physical health is: Good Fair Poor
Are you currently under the care of a physician? Yes No
If Yes, Please Explain:  
Do you smoke or use tobacco in any other form? Yes No
Have you had any metal rods, pins or implants? Yes No
Are you taking any prescription or over-the-counter drugs? Yes No
If Yes, Please Explain:  
Do you get cold sores? Yes No
Do you wear a cardiac pacemaker, or have you had heart surgery? Yes No
If Yes, When?  
Are you required to take any medication before your dental visit? Yes No
If Yes, What?  
For women:
Are you using a prescribed method of birth control? Yes No
Are you pregnant? Week #: Yes No
Are you nursing? Yes No
Have you ever had any of the following diseases or medical problems
Yes No Rheumatic Fever Yes No Thyroid Disease
Yes No Seizure Disorder Yes No Heart Disease
Yes No Anemia Yes No Kidney Disease
Yes No Heart Murmur (or MVP) Yes No Asthma
Yes No Venereal Disease Yes No High Blood Pressure
Yes No Diabetes Yes No Bleeding Problems
Yes No Tuberculosis Yes No Are you nursing
Yes No Cancer Yes No Aids/HIV
Yes No Artificial Joint / Heart Valve Yes No Psychiatric Treatment
Yes No Eating Disorders Yes No History of Endocarditis
Yes No Radiation Therapy: Head / Neck Yes No Alcohol and Drug Abuse
Yes No Arthritis Yes No Liver Disease
Yes No Hepatitis Type: A B C
Please list any serious medical condition(s) that you have ever had:
Are you allergic to any of the following?
Yes No Aspirin Yes No Erythromycin
Yes No Penicillin Yes No Sulfa drugs
Yes No Jewelry / Metals Yes No Codeine
Yes No Anesthetic (Novocain, etc.) Yes No Tetracycline
Yes No Latex Yes No Other
Please list any other drugs / Materials that you are allergic to:
Are You Now Taking:
Drugs for high blood pressure? Yes No Drugs for sleep? Yes No
Cortisone, steroids or ACTH? Yes No Insulin? Yes No
Tranquilizers or sedatives? Yes No Antibiotics? Yes No
Anticoagulants or blood thinner? Yes No
Please list any medications you are currently taking?

Dental Health and Appearance
Reason for visit:
Approximate date of last dental visit :
What is your primary concern that you would like us to address first?
When would you like us to start treatments?
Have you ever had any serious problem associated with previous dental treatment or any dental emergencies? Yes No
If Yes, Please Explain:  
What, if anything, has happened in previous experiences at the dentist that was reason not to return?
Do you ever feel (or have you ever been told) that you don't have fresh breath? Yes No
How often do you brush your teeth? time(s) a
How often do you floss? time(s) a
What type of brush do you use? Manual Powered
Do you avoid brushing any part of your mouth because of pain? Yes No
If Yes, What part?  
Which foods cause you twinges of pain : Hot Cold Sweet Sour None
Do your gums feel tender or swollen? Yes No
Do you chew on only one side of your mouth? Yes No
If so, Please Explain:  
Do you clench or girnd your jaws while sleeping or during the day? Yes No
Do your jaws ever feel tired? Yes No
Are you delighted with your smile? Yes No
Please rate your smile from 1 to 10 (1=I hate my smile, 10=Awesome) :
Would you like to have whiter teeth? Yes No
If you had a magic wand, what, if anything, would you change about your smile?
What (if any) personal or professional benefit might you gain if you had a gorgeous smile?
Do you have any special occastions coming up?

* I Understand That Payment Is Due At Time of Service.
I will pay today by:   CASH CHECK CREDIT CARD CARE CREDIT
* I verify that the preceding information is true. I authorize the release of information to the insurance company. I will allow Dr. Anirudh Patel and his associates to discuss the conditions with my physician(s) and to request medical information from them. I authorize the office of Dr. Anirudh Patel to obtain and verify a credit report.
* The information and health history and preceding answers are true and correct to the best of my knowledge. I authorize and give consent to perform dental services agreed between doctor and patient and/or guardian to be necessary or advisable, including the use of local anesthesia and other medications as indicated. I agree that, regardless of insurance coverage, I am responsible for payment for services rendered. If I ever have any changes in my health or if my medication change I will, without fail, inform the doctor at my next appointment.


*Signature
Date