Dental Registration and History Please fill out this form in its entirety. If you prefer to print a copy of this form to fill out by hand, you may do so by downloading the PDF version. Please bring it with you to your appointment or mail it in ahead of time. Patient Information Today's Date Invalid Input SS/HIC/Patient ID# Invalid Input Last Name Invalid Input First Name Invalid Input Middle Initial Invalid Input Address Invalid Input City Invalid Input State Invalid Input Zip Invalid Input Sex MaleFemale Invalid Input Age Invalid Input Birthday Month010203040506070809101112 / Day01020304050607080910111213141516171819202122232425262728293031 / Year19201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020 Invalid Input Marital Status MarriedSeparatedWidowedDivorcedSingleMinor Invalid Input Partnered for how many years? Invalid Input Patient Employer/School Invalid Input Occupation Invalid Input Employer/School Phone Invalid Input Employer/School Address Invalid Input Spouse's Name Invalid Input Birthdate Month010203040506070809101112 / Day01020304050607080910111213141516171819202122232425262728293031 / Year19201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020 Invalid Input SS# Invalid Input Spouse's Employer Invalid Input Whom may we thank for referring you? Invalid Input Next > Dental Insurance Who is responsible for this account? Invalid Input Relationship to Patient Invalid Input Insurance Company Invalid Input Group# Invalid Input Is patient covered by additional insurance? YesNo Invalid Input Subscriber's Name Invalid Input Birthdate Month010203040506070809101112 / Day01020304050607080910111213141516171819202122232425262728293031 / Year19201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020 Invalid Input SS# Invalid Input Relationship to Patient Invalid Input Insurance Company Invalid Input Group# Invalid Input Assignment and Release I certify that I, and/or my dependent(s), have insurance coverage with Invalid Input and assign directly to Waterville Community Dental Center all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above-named dentist/dental center may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below. Signature of Patient, Parent, Guardian or Personal Representative Invalid Input Please print name of Patient, Parent, Guardian or Personal Representative Invalid Input Today's Date Invalid Input Relationship to Patient Invalid Input < PrevNext > Phone Numbers Home Invalid Input Work Phone & Extension Invalid Input Alternate Phone Invalid Input Spouse's Work Invalid Input Best time and place to reach you Invalid Input In Case of Emergency, Contact (Specify someone who does not live in your household) Name Invalid Input Relationship to Patient Invalid Input Phone Invalid Input Alternate Phone Invalid Input < PrevNext > Dental History Reason for Today's Visit Invalid Input Former Dentist Invalid Input Date of last dental visit Invalid Input City/State Invalid Input Date of last dental x-rays Invalid Input Place a mark on "yes" or "no" to indicate if you have had any of the following: Bad breath YesNo Invalid Input Bleeding gums YesNo Invalid Input Blisters on lips or mouth YesNo Invalid Input Burning sensation on tongue YesNo Invalid Input Chew on one side of mouth YesNo Invalid Input Cigarette, pipe or cigar smoking YesNo Invalid Input Clicking or popping jaw YesNo Invalid Input Dry mouth YesNo Invalid Input Fingernail biting YesNo Invalid Input Food collection between the teeth YesNo Invalid Input Foreign objects YesNo Invalid Input Grinding teeth YesNo Invalid Input Gums swollen or tender YesNo Invalid Input Jaw pain or tiredness YesNo Invalid Input Lip or cheek biting YesNo Invalid Input Loose teeth or broken fillings YesNo Invalid Input Mouth breathing YesNo Invalid Input Mouth pain, brushing YesNo Invalid Input Orthodontic treatment YesNo Invalid Input Pain around ear YesNo Invalid Input Periodontal treatment YesNo Invalid Input Sensitivity to cold YesNo Invalid Input Sensitivity to heat YesNo Invalid Input Sensitivity to sweets YesNo Invalid Input Sensitivity when biting YesNo Invalid Input Sores or growths in your mouth YesNo Invalid Input How often do you floss? Invalid Input How often do you brush? Invalid Input < PrevNext > Health History Physician's Name Invalid Input Have you ever used a bisphosphonate medication? Common brand names are Fosamax, Actonel, Atelvia, Didronel, Boniva YesNo Invalid Input Date of Last Visit Invalid Input Have you ever taken any of the group of drugs collectively referred to as "fen-phen"? These include combinations of Ionimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine). YesNo Invalid Input Place a mark on "yes" or "no" to indicate if you have had any of the following: AIDS/HIV YesNo Invalid Input Anemia YesNo Invalid Input Arthritis, Rheumatism YesNo Invalid Input Artificial Heart Valves YesNo Invalid Input Artificial Joints YesNo Invalid Input Asthma YesNo Invalid Input Back Problems YesNo Invalid Input Bleeding abnormally, with extractions or surgery YesNo Invalid Input Blood Disease YesNo Invalid Input Cancer YesNo Invalid Input Chemical Dependency YesNo Invalid Input Chemotherapy YesNo Invalid Input Circulatory Problems YesNo Invalid Input Congenital Heart Lesions YesNo Invalid Input Cortisone Treatments YesNo Invalid Input Cough, persistent or bloody YesNo Invalid Input Diabetes YesNo Invalid Input Emphysema YesNo Invalid Input Do you wear contact lenses? YesNo Invalid Input Eiplepsy YesNo Invalid Input Fainting or dizziness YesNo Invalid Input Glaucoma YesNo Invalid Input Headaches YesNo Invalid Input Heart Murmur YesNo Invalid Input Heart Problems YesNo Invalid Input Hepatitis Type ABCDENo Invalid Input Herpes YesNo Invalid Input High Blood Pressure YesNo Invalid Input Jaundice YesNo Invalid Input Jaw Pain YesNo Invalid Input Kidney Disease YesNo Invalid Input Liver Disease YesNo Invalid Input Low Blood Pressure YesNo Invalid Input Mitral Valve Prolapse YesNo Invalid Input Nervous Problems YesNo Invalid Input Pacemaker YesNo Invalid Input Psychiatric Care YesNo Invalid Input Radiation Treatment YesNo Invalid Input Respiratory Disease YesNo Invalid Input Rheumatic Fever YesNo Invalid Input Scarlet Fever YesNo Invalid Input Shortness of Breath YesNo Invalid Input Sinus Trouble YesNo Invalid Input Skin Rash YesNo Invalid Input Special Diet YesNo Invalid Input Stroke YesNo Invalid Input Swollen Feet or Ankles YesNo Invalid Input Swollen Neck Glands YesNo Invalid Input Thyroid Problems YesNo Invalid Input Tonsillitis YesNo Invalid Input Tuberculosis YesNo Invalid Input Tumor or growth on head or neck YesNo Invalid Input Ulcer YesNo Invalid Input Venereal Disease YesNo Invalid Input Weight Loss, unexplained YesNo Invalid Input Women Are you pregnant? YesNo Invalid Input Due Date Invalid Input Are you nursing? YesNo Invalid Input Taking birth control pills? YesNo Invalid Input < PrevNext > Medications List any medications you are currently taking and the correlating diagnosis Invalid Input Pharmacy Name Invalid Input Pharmacy Phone Invalid Input < PrevNext > Allergies Allergies AspirinBarbiturates (Sleeping Pills)CodeineIodineLatexLocal AnestheticPenicillinSulfa Invalid Input Other Allergies Invalid Input < PrevSubmit
