Patient Information (Confidential)

Birth Date (YYYY/MM/DD)

Gender

Female Male Non-binary

Martial Status

Single Married Rather not to say

Emergency/Parent Contact

Emergency/Parent Phone

Parent/Guardian Information (Fill this section if the patient is a child or requires a guardian for making decision)

Person Responsible for This Account

How did you find us?

If you selected Family/Friend or other, whom shall we thank for your referral?

Primary Insurance Policy

Policyholder’s Name

Policyholder’s Date of Birth

Secondary Insurance Policy

Policyholder’s Name

Policyholder’s Date of Birth

Patient Medical History

Physician's Office Phone

1. Are you currently under any medical treatment?

Yes No

2. Have you been admitted to a hospital or needed emergency care during the past two years?

Yes No

3. Are you currently taking any medications, including over the counter medications?

Yes No

4. Have you ever had any complications following dental treatment?

Yes No

5. Do you have or have had any of the following? Please check all that apply.

6. Are there any conditions or diseases not listed above that you have or ever had?

Yes No

If yes, please explain

7. Are there any diseases or medical problems that run in your family? (e.g. diabetes, cancer, or heart disease)

Yes No

If yes, please explain

8. Do you have a history of snoring/sleep apnea?

Yes No

If so do you use a mouth breather?

Yes No

Do you often find it difficult to breathe through your nose?

Yes No

9. WOMEN ONLY: Are you breast feeding?

Yes No

10. WOMEN ONLY: Are you pregnant?

Yes No

11. WOMEN ONLY: What is your due date?

12. Do you have any allergies to medications?

Yes No

13. Please list your allergies to any medications

1. Have you ever had trouble getting numb or had any reactions to local anesthetic?

Yes No

2. Did you ever have braces, orthodontic treatment, or had your bite adjusted?

Yes No

3. Have you had any teeth removed or missing teeth that never developed?

Yes No

4. Do your gums bleed or are they painful when brushing or flossing?

Yes No

5. Have you ever been treated for gum disease or been told you have lost bone around your teeth?

Yes No

6. Have you ever noticed an unpleasant taste or odor in your mouth?

Yes No

7. Is there anyone with a history of periodontal disease in your family?

Yes No

8. Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?

Yes No

9. Have you experienced a burning or painful sensation in your mouth not related to your teeth?

Yes No

10. Have you had any cavities within the past 3 years?

Yes No

11. Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?

Yes No

12. Are any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth?

Yes No

13. Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?

Yes No

14. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)

Yes No

15. Are your teeth becoming more crooked, crowded, or overlapped?

Yes No

16. Are your teeth developing spaces or becoming more loose?

Yes No

17. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?

Yes No

18. Do you clench your teeth in the daytime or make them sore?

Yes No

19. Do you have any problems with sleep (i.e. restlessness), wake up with a headache or an awareness of your teeth?

Yes No

20. Do you wear or have you ever worn a bite appliance?

Yes No

Smile Characteristics

21. Is there anything about the appearance of your teeth that you would like to change?

Yes No

22. Have you felt uncomfortable or self conscious about the appearance of your teeth?

Yes No

At DentiFlow Dental Clinic, all efforts will be made to accommodate your schedule. If you need to make any changes to your appointment we ask that you provide us with 2 business days advance notice. This courtesy on your part will allow us to arrange for the time that was initially reserved just for you to be given to another patient that is in need of care. Failure to provide notice may result in a minimum charge of $50 to your account. Our team will make every effort to ensure that we are on time for you! We expect that you will make the same effort and ensure that you are on time for your appointment. Be there a few minutes early to update your medical, insurance and contact information. Please be aware that if you are late for a scheduled appointment, we may need to reschedule you to ensure that our patients who arrive on time are seen on time.

I have read and understand the above cancellation policy.

Name (Patient/Parent/Legal Guardian)

Consent for Services

I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my medical-dental history. I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I also understand that consultation with my medical doctor may be required, and I consent to my physician being contacted as necessary. I understand that responsibility for the payment for the dental services provided for myself and dependents is mine, and I will assume responsibility for fees associated with these services.

I have read and understand the above consent for services.

Name (Patient/Parent/Legal Guardian)

New Patient Registration Form

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