Online Registration

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Patient Information

Parental Information

Emergency Contact

Insurance Information

Health History
Patient information
First Name*
Last Name*
Sex*
Date of Birth*
MM slash DD slash YYYY
SSN
Age*
Address*
State*
City*
Zip Code*
Home Phone
Cell Phone
Primary Phone
- Make Home Phone Primary
- Make Cell Phone Primary
Employer Name
Name of Dentist
Name of Physician
Name of Orthodontist
Referring Doctor
Have you ever been a patient of this practice?
Have you ever been a patient of this practice?
- Yes
- No
Has a family member ever been a patient of this practice?
Has a family member ever been a patient of this practice?
- Yes
- No
Please upload any radiograph, photographs, referral notes or relevant information

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Parental Information (If Patient is a Minor or Student)
Mother First Name
Mother Last Name
Mother Employer
Mother Day of Birth
MM slash DD slash YYYY
Mother SSN
Mother Telephone
Father First Name
Father Last Name
Father Employer
Father Day of Birth
MM slash DD slash YYYY
Father SSN
Father Telephone
Emergency Contact
Emergency Contact First Name*
Emergency Contact Last Name*
Emergency Contact Employer
Emergency Contact Cell Phone*
Emergency Contact Alt Phone
Dental (Primary)
Dental Primary - Insurance Company Name
Dental Primary - Group Number
Dental Primary - Identification Number
Dental Primary - Address
Dental Primary - Telephone Number
Dental Primary - Name of Policy Holder
Dental Primary - Relation to Policy Holder
Medical (Primary)
Medical Primary - Insurance Company Name
Medical Primary - Group Number
Medical Primary - Identification Number
Medical Primary - Address
Medical Primary - Telephone Number
Medical Primary - Name of Policy Holder
Medical Primary - Relation to Policy Holder
Dental (Secondary)
Dental Secondary - Insurance Company Name
Dental Secondary - Group Number
Dental Secondary - Identification Number
Dental Secondary - Address
Dental Secondary - Telephone Number
Dental Secondary - Name of Policy Holder
Dental Secondary - Relation to Policy Holder
Medical (Secondary)
Patient information
Medical Secondary - Insurance Company Name
Medical Secondary - Group Number
Medical Secondary - Identification Number
Medical Secondary - Address
Medical Secondary - Telephone Number
Medical Secondary - Name of Policy Holder
Medical Secondary - Relation to Policy Holder
Consent - I have read and I understand the questions above*
I certify that I have read and I understand the questions 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 doctor, or any other member of his / her staff, responsible for any errors or omissions that I have made in the completion of this form.
Consent - oral and maxillofacial examination*
I authorize my surgeon and his / her designated staff, to perform an oral and maxillofacial examination, for the purpose of diagnosis and treatment planning. Furthermore, I authorize the taking of all x–rays required as a necessary part of this examination. In addition, if medically necessary, I authorize the release of any information acquired in the course of my examination and treatment to my other doctors and/or insurance carriers. I permit messages to be left on my phone and/or mobile phone concerning my appointment.
Consent - FEES & PAYMENTS*
FEES & PAYMENTS We make every effort to keep down the cost of your care. You can help by paying upon completion of each visit. An estimate of the charge for any procedure or surgery you may require will be given to you upon request. If you have any dental and/or medical insurance we will be glad to fill out the proper forms, but please complete the identifying information on this form.
Consent - insurance*
Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid for by your insurance company. . You will be responsible for all collection costs, attorney fees, and court costs.
Consent - video and/or photographic recording
I hereby authorize video and/or photographic recording of any and all portions of my treatment performed by Dr. Michael Hartman and Dr. David Sibley. I understand this video may be used for non-profit purposes such as education, consultation, research and/or quality assurance. I understand that, while my identity will not be directly disclosed at any time in the records and all attempts will be made to conceal my identity it may be possible to identify me visually.
Consent - copy of notice*
I hereby acknowledge that a copy of this office’s Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions I may have regarding this Notice.
Health History - Full Name*
Health History - Date of Birth
MM slash DD slash YYYY
Health History - Height
Health History - Weight
- Are you in good health?
  - Yes
  - No
  Are you in good health?
- Have there been any changes in your health in the past year?
  - Yes
  - No
  Have there been any changes in your health in the past year?
- Are you under the care of a physician?
  - Yes
  - No
  Are you under the care of a physician?
- Date of last visit
  MM slash DD slash YYYY
  
  Date of last visit
- For what are you being treated?
  
  For what are you being treated?
- Have you had any illness, operation, or hospitalization in the past five years?
  - Yes
  - No
  Have you had any illness, operation, or hospitalization in the past five years?
- Describe 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?
  - Yes
  - No
  Do you have unhealed/recurrent injuries or inflamed areas, growths, or sore spots in your mouth?
- Describe unhealed/recurrent injuries
  
  Please describe:
- Do you have a prosthetic joint/implant?
  - Yes
  - No
  Do you have a prosthetic joint/implant?
- Describe prosthetic joint/implant
  
  Please describe:
- Have you had a heart valve replacement or vascular graft?
  - Yes
  - No
  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)?
  - Yes
  - No
  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?
  - Yes
  - No
  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?
  - Yes
  - No
  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
  - Yes
  - No
  Rheumatic Fever
- Damaged heart valves/mitral valve prolapse
  - Yes
  - No
  Damaged heart valves/mitral valve prolapse
- Heart murmur
  - Yes
  - No
  Heart murmur
- High blood pressure
  - Yes
  - No
  High blood pressure
- Low blood pressure
  - Yes
  - No
  Low blood pressure
- Chest pain/angina
  - Yes
  - No
  Chest pain/angina
- Heart attack(s)
  - Yes
  - No
  Heart attack(s)
- Irregular heart beat
  - Yes
  - No
  Irregular heart beat
- Cardiac pacemaker
  - Yes
  - No
  Cardiac pacemaker
- Heart surgery
  - Yes
  - No
  Heart surgery
- Pneumonia, bronchitis, chronic cough (Current)
  - Yes
  - No
  Pneumonia, bronchitis, chronic cough (Current)
- Asthma
  - Yes
  - No
  Asthma
- Hay fever/sinus problems
  - Yes
  - No
  Hay fever/sinus problems
- Sring/sleep apnea
  - Yes
  - No
  Sring/sleep apnea
- Difficult breathing/other lung trouble
  - Yes
  - No
  Difficult breathing/other lung trouble
- Tuberculosis
  - Yes
  - No
  Tuberculosis
- Emphysema
  - Yes
  - No
  Emphysema
- Do you smoke?
  - Yes
  - No
  Do you smoke?
- Do you use chewing tobacco
  - Yes
  - No
  Do you use chewing tobacco
- Blood transfusion
  - Yes
  - No
  Blood transfusion
- Blood disorder such as anemia
  - Yes
  - No
  Blood disorder such as anemia
- Bruise easily
  - Yes
  - No
  Bruise easily
- Bleeding tendency/abnormal bleed
  - Yes
  - No
  Bleeding tendency/abnormal bleed
- Hepatitis, jaundice, or liver disease
  - Yes
  - No
  Hepatitis, jaundice, or liver disease
- Gallbladder trouble
  - Yes
  - No
  Gallbladder trouble
- Fainting spells
  - Yes
  - No
  Fainting spells
- Convulsions/epilepsy
  - Yes
  - No
  Convulsions/epilepsy
- Stroke
  - Yes
  - No
  Stroke
- Thyroid trouble
  - Yes
  - No
  Thyroid trouble
- Diabetes
  - Yes
  - No
  Diabetes
- Low blood sugar
  - Yes
  - No
  Low blood sugar
- Kidney trouble
  - Yes
  - No
  Kidney trouble
- High cholesterol
  - Yes
  - No
  High cholesterol
- Are you on dialysis?
  - Yes
  - No
  Are you on dialysis?
- Swollen ankles/ arthritis/ joint disease
  - Yes
  - No
  Swollen ankles/ arthritis/ joint disease
- Osteoporosis/ osteopenia
  - Yes
  - No
  Osteoporosis/ osteopenia
- Osteonecrosis
  - Yes
  - No
  Osteonecrosis
- Stomach ulcers/ acid reflux
  - Yes
  - No
  Stomach ulcers/ acid reflux
- Contagious diseases
  - Yes
  - No
  Contagious diseases
- Sexually transmitted diseases
  - Yes
  - No
  Sexually transmitted diseases
- Immune system problems (possibly from medication/ surgery, etc)
  - Yes
  - No
  Immune system problems (possibly from medication/ surgery, etc)
- Delay in healing
  - Yes
  - No
  Delay in healing
- Tumor or growth
  - Yes
  - No
  Tumor or growth
- Cancer/ radiation therapy/ chemotherapy
  - Yes
  - No
  Cancer/ radiation therapy/ chemotherapy
- Chronic fatigue/ night sweats
  - Yes
  - No
  Chronic fatigue/ night sweats
- History of alcohol/ drug abuse
  - Yes
  - No
  History of alcohol/ drug abuse
- Contact lenses
  - Yes
  - No
  Contact lenses
- Eye disease/ glaucoma
  - Yes
  - No
  Eye disease/ glaucoma
- Autism
  - Yes
  - No
  Autism
- Mental health problems/ anxiety/ depression
  - Yes
  - No
  Mental health problems/ anxiety/ depression
- Joint Replacement
  - Yes
  - No
  Joint Replacement
- Removable dental appliance
  - Yes
  - No
  Removable dental appliance
- Pain or clicking of jaw
  - Yes
  - No
  Pain or clicking of jaw
- Social History
- Do you smoke?
  - Yes
  - No
  Do you smoke?
- Smoke - how much?
  
  How much?
- Do you drink?
  - Yes
  - No
  Do you drink?
- Drink - how much?
  
  How much?
- Do you use drugs?
  - Yes
  - No
  Do you use drugs?
- Drugs - how much?
  
  How much?
- Is there a family history of:
- Family history - Cancer
  - Yes
  - No
  Cancer
- Family history - Heart Disease
  - Yes
  - No
  Heart Disease
- Family history - Diabetes
  - Yes
  - No
  Diabetes
- Family history - Anesthesia Problems
  - Yes
  - No
  Anesthesia Problems
- Family History is Unknown
  - history
  Click Here If Family History is Unknown
- Please list any surgeries you have had in the past:
- Surgeries
- Please list any allergies you have had in the past:
- Allergy - Local anesthetic (numbing agents)
  - Yes
  - No
  Local anesthetic (numbing agents)
- Allergy - Penicillin
  - Yes
  - No
  Penicillin
- Allergy - Other Antibiotics
  - Yes
  - No
  Other Antibiotics
- Allergy - Sulfa Drugs
  - Yes
  - No
  Sulfa Drugs
- Allergy - Sodium Pentothal/Valium/Tranquilizers
  - Yes
  - No
  Sodium Pentothal/Valium/Tranquilizers
- Allergy - Aspirin
  - Yes
  - No
  Aspirin
- Allergy - Amoxicillin
  - Yes
  - No
  Amoxicillin
- Allergy - Codeine or other narcotics (Specify)
  - Yes
  - No
  Codeine or other narcotics (Specify)
- Allergy - Other Medications
  - Yes
  - No
  Other Medications
- Allergy - Latex
  - Yes
  - No
  Latex
- Allergy - Soy
  - Yes
  - No
  Soy
- Allergy - Eggs/Yolk
  - Yes
  - No
  Eggs/Yolk
- Allergy - Sulfites
  - Yes
  - No
  Sulfites
- Are you now taking:
- Taking - Blood thinners
  - Yes
  - No
  Blood thinners (Coumadin, Plavix, Aspirin, Pradaxa)
- Are you taking medications to strengthen your bones
  - Yes
  - No
  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?
  
  If so, when?
- Please list any medications/supplements you are currently taking:
- Medications and supplements
- If you are having surgery today, have you had anything to eat or drink in the last 8 (eight) hours?
  - Yes
  - No
  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?
  
  Who is driving you home?
- Who is driving you home - phone
  Phone:
- Is there any condition concerning your health that the doctor should be told about?
  - Yes
  - No
  Is there any condition concerning your health that the doctor should be told about?
- Condition concerning your health
  
  If yes, please describe:
- Do you wish to speak with the doctor privately about anything?
  - Yes
  - No
  Do you wish to speak with the doctor privately about anything?
- Is this visit related to an accident?
  - Yes
  - No
  Is this visit related to an accident?
- Related to accident
  
  If yes, please describe:
Please list any additional allergies:
Allergies
I certify that I have read and I understand the questions above*
I certify that I have read and I understand the questions 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 doctor, or any other member of his / her staff, responsible for any errors or omissions that I have made in the completion of this form.

Online Registration

Patient information

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

Parental Information (If Patient is a Minor or Student)

Emergency Contact

Patient information

Have you had, or do you have:

Have you had, or do you have:

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