Patient Registration


If you prefer, you may leave portions of this registration blank if you are uncomfortable providing the information electronically, please call our office to provide the information via phone or provide the information when you come in for your office visit.

General Patient Information



Emergency Contact


Physicians Information



Medical History

Are you in good health?

YesNo

Have you seen a physician in the last year?

YesNo

Were you seen for a routine physical exam only?

YesNo

Are you presently under medical care?

YesNo

Have you ever been hospitalized?

YesNo

Have you ever had surgery?

YesNo

Have you ever had RHEUMATIC FEVER?

YesNo

Have you ever been told by a physician that you have RHEUMATIC HEART DISEASE?

YesNo

Have you ever been told by a physician that you have a HEART MURMUR?

YesNo

Have you ever been told by a doctor that you need a premedicate before dental treatment?

YesNo

Have you ever had HEPATITIS or JAUNDICE (yellow skin or eyes)?

YesNo

Have you ever been told that you have LIVER DISEASE?

YesNo

Have you ever had EPILEPSY or SEIZURES?

YesNo

Do you urinate often or wake up in the night to urinate?

YesNo

Have you ever had DIABETES?

YesNo

Have you ever had KIDNEY TROUBLE?

YesNo

Have you ever had HIGH BLOOD PRESSURE?

YesNo

Do you have chest pain or exertion?

YesNo

Have you ever had HEART TROUBLE or a HEART ATTACK?

YesNo

Do you have a PACE MAKER?

YesNo

Have you ever had a PROSTHETIC HEART VALVE REPLACEMENT?

YesNo

Have you ever had VENEREAL DISEASE?

YesNo

Have you ever had THYROID DISEASE?

YesNo

Have you ever had TUBERCULOSIS?

YesNo

Have you ever had PROLONGED BLEEDING?

YesNo

Have you ever had a BLOOD DISEASE or DISORDER?

YesNo

Have you ever had PAINFUL or SWOLLEN JOINTS?

YesNo

Do you have any PROSTHETIC REPLACEMENTS?

YesNo

Have you ever had a TUMOR or GROWTH?

YesNo

Do you have ASTHMA?

YesNo

Do you have or have you ever been exposed to HIV/AIDS?

YesNo

Have you ever had a problem from the administration of local anesthetic?

YesNo

Have you ever had an ALLERGIC response to any antibiotic?

If yes, please list:

YesNo

Have you ever had an ALLERGIC response to any other medication?

If yes, please list:

YesNo

Have you ever been treated for CHRONIC TENSION or MIGRAINES?

YesNo

Do you clench, grind or brux your teeth?

YesNo

Have you ever been treated for ULCERS or NERVOUSNESS?

YesNo

Do you have a history of chronic DIZZINESS or FAINTING?

YesNo

Have you ever been told that you are ANEMIC?

YesNo

Do you have recurrent or chronic SINUS problems?

YesNo

Have you lost weight without dieting in the past few months?

YesNo

Are you now or have you in the past six months been treated with steroids?

YesNo

Are chills and/or night sweats common?

YesNo

Do you have any unexplained swelling or tenderness in your lymph glands?

YesNo

Do you have chronic DIARRHEA?

YesNo

Do you often feel tired and/or confused?

YesNo

Is there anything about your medical history that has not been covered, that you feel is important for us to know?

If yes, please describe here:

YesNo

If any, what medications are you currently taking?


WOMEN: Are you pregnant?

YesNo

Are you enrolled in a DENTAL PLAN?

YesNo



I, the undersigned, consent to receive this consultation and should I agree to accept professional advice, also consent to the performing of whatever procedure may be decided upon to be necessary or advisable in the opinion of the doctors.

I also understand that only the root canal treatment is to be performed in this office. The permanent (outside) restoration (filling, inlay, crown, etc.) will be done by my regular dentist.

I also acknowledge full responsibility for the payment of such services. Unless other arrangements are made in advance, payment is expected as service is rendered.