Microsoft word - new-patient-registration-form

BestCare Family Dental
88-09 Northern Boulevard
Jackson Heights, N.Y. 11372
(718) 429-7744
Name _________________________________ Address __________________________________________________________________________________ Emergency Contact: Name ___________________ Dental Insurance: Phone _____________________ If you are completing this form for another person, what is your relationship to that person? ___________________ Referred by ___________________________________________ HAVE YOU HAD:
Are you in good general health?
Are you now taking any drugs or medications? (Novocaine or Xylocaine) by a dentist or doctor? Have you ever had any adverse reaction to either Do you take aspirin products or anti-inflammatory Other:_________________________________________ PLEASE LIST ALL PREVIOUS SURGERIES AND DATES:
Have dentures, false teeth, caps or bridges __________________________________________________ _________________________________________________ Have any contagious or infectious condition Dental Questionnaire:

NO YES Are you happy with your smile?
NO YES Are you interested in straighter teeth (Invisalign)?
NO YES Would you like to change the whiteness of your teeth and/or fillings?
NO YES Are you interested in replacing missing teeth?
NO YES Do your gums bleed?
NO YES Do you have bad breath/unpleasant taste?
NO YES Do you have swelling/lumps in your mouth?
NO YES Are your teeth sensitive to cold/hot/sweets/pressure?
NO YES Do you clench/grind your teeth?
NO YES Have you had an unfavorable dental experience? Please explain: __________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Chief Dental Complaints ______________________________________________________________________________________
____________________________________________________________________________________________________________

The above information is strictly confidential
I certify that I have read and understood the above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form.
For completion by the dentist.
Comments on patient interview concerning medical history:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Significant findings from questionnaire or oral interview: ____________________________________________________________
______________________________________________________________________________________________________________

______________________________________________
Signature of Dentist
Medical History Update:
Date
Comments
Signature
_______________ ____________________________
___________________
_______________ ____________________________
___________________
_______________ ____________________________
___________________

Source: http://www.bestcarefd.com/docs/New-Patient-Registration-Form.pdf