Please complete this confidential registration form, as your medical and dental health history are essential to determine the course or your treatment.

Once you've accurately completed the form, click the "submit" button below.







Patient Information
Title: First Name: Last Name:
Date of Birth: / / (mm/dd/yyyy)
Street Address: Apt: City: P.Code:
Home Phone: Bus. Phone: Cell:
Email: Confirm Email:
Occupation: Employer:

Insurance Information
Primary Policy Holder Name:Birthdate:
/ / (mm/dd/yyyy)
Insurance Company Name:Policy/Group#:ID#:
Secondary Policy Holder Name:Birthdate:
/ / (mm/dd/yyyy)
Insurance Company Name:Policy/Group#:ID#:
Name of Spouse/Parent:Phone:
Name of Family Doctor:Phone:Referring Dentist:

Dental History
Have you ever had an unfavourable reaction after a dental treatment? Yes No
If yes, explain:
Are you currently in pain? Yes No
Main Complaint:
Are any of your teeth sensitive to the following?
If other, explain:

Health History
Have you ever had excessive bleeding requiring special treatment? Yes No
Do you wear contact lenses? Yes No
Female patients, are you or could you be pregnant or nursing? Yes No
If pregnant, which month?

Check any of the following that you have or had in the past:








Do you have any other medical problems not listed here? Specify below:

Please list any allergies to medications:

Please list medications you are currently taking:
                         
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