Adult Patient Information

Adult Registration Form - Dental
* required field

Patient Information

Spouse/Emergency Contact Information

Insurance Information

Dental History

Name of person referring (if applicable)
How did you hear about our Practice?
Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)?
Are your teeth sensitive to cold, hot, or sweets?
Do your gums bleed?
Do you use tobacco (smoking, snuff, chew) or electric cigarettes?
Have you had periodontal (gum) treatment?
Have you had orthodontic treatment (braces)?
Do you currently or have you ever had any of the following habits?

Medical History

Are you currently being treated by a physician?

Are you allergic to or have had a reaction to any of the following?
Are you currently taking any prescription or over-the-counter medications?
Are you taking or have taken any diet drugs such as Pondimin, Redux, of Phen-phen?
Have you had any serious illnesses or operations? If yes, describe:
Check if you have or have ever had any of the following:
If you marked artificial joint please answer the next two questions


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. Both doctor and patient are encouraged to discuss any and all patient health issues prior to treatment. I will not hold dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

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