Registration

General Information

Your Name (required)

Your Email (required)

Preferred Name

Date of Birth

Home #

Cell #

Address

City: State: Zip:

Employer

Employer

Work #

Spouse

Spouse’s Name

Date of Birth

Employer

Work #

Children

If patient is a child:

Father’s Name

Employer

Work #

Mother’s Name

Employer

Work #

Dental Insurance

Insurance Company

Subscriber’s Name

Subscriber’s Date of Birth

ID #

Group #

Emergency

Name and Phone # of 2 persons whom we may contact in case of emergency

Name of previous dentist where records could be obtained, if necessary

Referral

Whom may we thank for this referral?

Our Payment Policy

PAYMENT IS DUE AS SERVICES ARE RENDERED. We will gladly file your insurance claim for you. A service charge of .66% per month (7.92% annually) will be automatically added to any balance over 60 days. A $25.00 fee will be charged on all returned checks.

I understand that responsibility for payment for dental services provided in this office for myself, or my dependents, is mine, due and payable at the time services are rendered unless financial arrangements have been made. If insured, I authorize any insurance payment to go directly to Sapphire Family Dental.

Patient Medical History

General Information

Reason for visit

Date of last dental visit/

Date of last dental x-rays

Physician Information

Physician or Clinic Name

Physician/Clinic Phone or Location

Pharmacy

Pharmacy Phone

Other Information

How often do you brush?

How often do you floss?

Do you smoke or use tobacco products?

Please list any medication you are now taking

*It is especially important to know if you are taking bone/osteoporosis medications (Fosamax,Boniva, Prolia, Reclast, or Actonel) tranquilizers, phenobarbital or dilantin, blood thinners (aspirin, Warfarin/Coumadin, Plavix, Xarelto, Eliquis), steroid medicines, nitroglycerin, arthritis or thyroid medicine.

MaleFemale

If Female

Are you taking Birth Control Pills?

Are you pregnant? If yes, # of weeks

Are you nursing?

Yes or No

YesNo Are you having pain or discomfort now? If so, what?
YesNo Do your gums bleed when you brush?
YesNo Have you had periodontal or gum treatment?
YesNo Have you had any undesirable treatment experience? If so, what?
YesNo Do you have any sores or lumps in your mouth that don’t heal?
YesNo Are you unhappy with your smile? If so, why?
YesNo Have you had orthodontic treatment?
YesNo Are you currently under a physician’s care? If so, for what?
YesNo Have you had any illness or surgery in the past year? If so, what?
YesNo Are you changing dentists for any particular reason? If so, why?

Conditions: Check all that apply

Acid Reflux/GERD
ADD/ADHD
Allergies
Anemia
Angina Pectoris/ Chest Pain
Arthritis
Artificial Joints
Artificial Heart Valve
Asthma
Blood Transfusion
Cancer-Chemotherapy
Chemical Dependency
Congenital Heart Defect
Congestive Heart Failure
C-PAP machine/Sleep Apnea
Dental Implants
Diabetes
Difficulty Breathing
Eating Disorders
Emphysema
Epilepsy
Fainting Spells
Frequent Headaches
Glaucoma
Hay Fever
Heart Attack
Heart Murmur
Heart Surgery
Hemophilia or Clotting Disorder
Hepatitis A, B and/or C
Herpes/Cold Sores
High Blood Pressure
High Cholesterol
HIV+ AIDS
Joint Replacement
Kidney Problems
Liver Disease
Low Blood Pressure
Mitral Valve Prolapse
Organ Transplant
Pacemaker/Internal Defibrillator
Mental Health Care
Radiation Therapy
Rheumatic Fever
Seizures
Sickle Cell Disease
Sinus Problems
Stroke
Thyroid Problems
Tuberculosis
Ulcers

Allergies

Aspirin
Codeine
Dental Anesthetics
Erythromycin
Jewelry
Latex
Metals
Penicillin
Tetracycline
Sulfa
Other

Other Information

List any disease or condition no listed above