Online Registration

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  • Patient Information
    Parental Information
    Emergency Contact
    Insurance Information
    Health History
  • Patient information
  • MM slash DD slash YYYY
  • Have you ever been a patient of this practice?
  • Has a family member ever been a patient of this practice?
  • Please upload any radiograph, photographs, referral notes or relevant information

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    • Parental Information (If Patient is a Minor or Student)
    • MM slash DD slash YYYY
    • MM slash DD slash YYYY
    • Emergency Contact
    • Dental (Primary)

    • Medical (Primary)

    • Patient information
    • MM slash DD slash YYYY
        Are you in good health?
        Have there been any changes in your health in the past year?
        Are you under the care of a physician?
      • MM slash DD slash YYYY
        Date of last visit
      • For what are you being treated?
        Have you had any illness, operation, or hospitalization in the past five years?
      • Please describe:
        Do you have unhealed/recurrent injuries or inflamed areas, growths, or sore spots in your mouth?
      • Please describe:
        Do you have a prosthetic joint/implant?
      • Please describe:
        Have you had a heart valve replacement or vascular graft?
        Have you or a family member had any unusual or serious reactions to general anesthesia (Specify)?
        Has a physician or dentist ever recommended that you take antibiotics prior to dental treatment?
        Do you take antibiotics regularly or prior to dentist visits?
    • Have you had, or do you have:
    • Have you had, or do you have:
        Rheumatic Fever
        Damaged heart valves/mitral valve prolapse
        Heart murmur
        High blood pressure
        Low blood pressure
        Chest pain/angina
        Heart attack(s)
        Irregular heart beat
        Cardiac pacemaker
        Heart surgery
        Pneumonia, bronchitis, chronic cough (Current)
        Hay fever/sinus problems
        Sring/sleep apnea
        Difficult breathing/other lung trouble
        Do you smoke?
        Do you use chewing tobacco
        Blood transfusion
        Blood disorder such as anemia
        Bruise easily
        Bleeding tendency/abnormal bleed
        Hepatitis, jaundice, or liver disease
        Gallbladder trouble
        Fainting spells
        Thyroid trouble
        Low blood sugar
        Kidney trouble
        High cholesterol
        Are you on dialysis?
        Swollen ankles/ arthritis/ joint disease
        Osteoporosis/ osteopenia
        Stomach ulcers/ acid reflux
        Contagious diseases
        Sexually transmitted diseases
        Immune system problems (possibly from medication/ surgery, etc)
        Delay in healing
        Tumor or growth
        Cancer/ radiation therapy/ chemotherapy
        Chronic fatigue/ night sweats
        History of alcohol/ drug abuse
        Contact lenses
        Eye disease/ glaucoma
        Mental health problems/ anxiety/ depression
        Joint Replacement
        Removable dental appliance
        Pain or clicking of jaw
      • Social History

        Do you smoke?
      • How much?
        Do you drink?
      • How much?
        Do you use drugs?
      • How much?
      • Is there a family history of:

        Heart Disease
        Anesthesia Problems
        Click Here If Family History is Unknown
      • Please list any surgeries you have had in the past:

      • Please list any allergies you have had in the past:

        Local anesthetic (numbing agents)
        Other Antibiotics
        Sulfa Drugs
        Sodium Pentothal/Valium/Tranquilizers
        Codeine or other narcotics (Specify)
        Other Medications
      • Are you now taking:

        Blood thinners (Coumadin, Plavix, Aspirin, Pradaxa)
        Are you taking, or have you previously taken any medications to strengthen your bones (for osteoporosis or bone cancer). These medications are also known as anti-resorptive medications. Examples are Fosamax, Boniva, Prolia, Actonel, Aredia, Xgeva, Zometa, Avastin. Penicllin
      • If so, when?
      • Please list any medications/supplements you are currently taking:

        If you are having surgery today, have you had anything to eat or drink in the last 8 (eight) hours?
      • Who is driving you home?
      • Phone:
        Is there any condition concerning your health that the doctor should be told about?
      • If yes, please describe:
        Do you wish to speak with the doctor privately about anything?
        Is this visit related to an accident?
      • If yes, please describe:
    • Please list any additional allergies:

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