Complete Your Adult Registration Form Online

Gender:(Required)
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Marital status:
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Did you visit our website?

Other family members seen by us?

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Previous/Present Dentist:

Spouse Information

Person Responsible For Account

In The Event Of An Emergency, Who Should We Contact?

Dental Insurance Information

Primary Insurance

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Secondary Insurance

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Medical and Dental History

Do you have a personal Physician?
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Your current physical health is:
Are you currently under the care of a physician?
Are you taking any prescription / over the counter drugs?
Have you ever taken any anti-osteoporosis drugs?
Have you ever been sleep tested?
Have you ever been diagnosed with sleep apnea or obstructive sleep apnea?
Has a CPAP device been recommended to you for sleep apnea?
Do you use a CPAP device regularly?
Would you be interested in an oral device to replace your CPAP mask?
Do you have a history of previous surgeries?

For Women:

Are you taking birth control pills?
Are you nursing?
Are you pregnant?

Have you ever had any of the following diseases or medical problems?

Anemia:
Asthma:
Arthritis:
Artificial valves:
Bariatric Surgery:
Blood Transfusion:
Colitis:
Diabetes:
Difficulty Breathing:
Emphysema:
Epilepsy / Seizures:
Fainting Spells:
Fever blisters:
Glaucoma:
Heart attack:
Heart murmur:
Hepatitis:
HIV+ / AIDS:
Rheumatic fever:
Shingles:
Sinus problems:
Stroke:
Ulcers:
Tuberculosis(TB):
Kidney problems:
Venereal Disease:
Heart surgery / Pacemaker:
Hemophilia / Abnormal Bleeding:
Artificial bones / Joints:
High / Low blood pressure:
Hospitalized for any reason:
Cancer / Chemotherapy:
Cardiac Surgery / Stent Surgery:
Mitral Valve prolapse:
Psychiatric Problems:
Congenital Heart Defect:
Radiation Treatment:
Severe / Frequent headaches:
Drug / Alcohol Abuse:

Are you allergic to any of the following?

Any metal:
Latex:
Aspirin:
Penicillin:
Codeine:
Plastic:
Dental Anesthetics:
Tetracycline:
Erythromycin:
Other:

Dental History

Are you currently in pain?
Have you ever had a serious / Difficult problem associated with any previous dental work?
Do you have or have you ever experienced pain / Discomfort in your jaw joint (TMJ / TMD)?
Your current dental health is:
Do you like your smile?
Do your gums ever bleed?
Type of bristles?
Have you ever been told that you should be medicated with a drug prior to your dental appointments?
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