New Custom Form Adult

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We believe that excellent care begins with open communication. If you need more information, have any questions, or want to schedule an appointment, please contact us!


Custom Adult Registration Form

1. About You

Marital Status:

2. Spouse Information

2a. Responsible Party

3a. Primary Insurance

Dental Coverage:
Ortho Coverage:

3b. Secondary Insurance

Dental Coverage:
Ortho Coverage:

In the event of an emergency, is there someone who lives near you that we should contact?

4. Medical History

Do you have a personal physician?
Your current physical health is:
Are you currently under the care of a physician?
Are you taking any prescription / over-the-counter drugs?
For Women: Are you using a prescribed method of birth control?
Are you pregnant?
Are you nursing?
Have ever had any of the following diseases or medical problems?
Are you allergic to any of the following?

5. Dental History

Have you ever had a serious / difficult problem associated with any previous dental work?
Do you now or have you ever experienced pain / discomfort in your jaw joint (TMJ / TMD)?
Your current dental health is:
Do you like your smile?
Gums ever bleed?
Have you ever had an injury to your (select all that apply):
Do you generally breathe through your mouth?
If yes:
Do you have any missing or extra permanent teeth?
Have you ever taken Fosamax, or any other bisphosphonate?
Have you ever taken Phen-Fen?
Do you smoke or use tobacco in any form?

6. Authorization

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 confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.

This office reserves the right to verify the credit status of potential patients and / or parents of patients prior to extending credit for treatment fees and may, at the discretion of the office, use the services of one or more credit reporting services.

Thank you for filling out this form completely.

If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment of the group insurance benefits (otherwise payable to me) directly to this office.

Our office is HIPAA Compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

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