New Patient Registration

Card Information

Personal Information

Are you a Full Time/Part Time student?
Do you have dental insurance?

Medical Information

Have you ever been hospitalized or had an operation?
Were you or are you taking any prescription or non-prescription medications or vitamins?
Are you allergic to any prescription or non-prescription medication?
Do you have any food allergies?
Do you have any environmental allergies?
Do you experience fainting, dizzy spells, nervous disorders, seizures, convulsions, or epilepsy?
Have you ever received psychiatric treatment or had any type of mental illness?
Have you ever experienced breathing difficulties?
If yes, please select all that apply.
Have you ever experienced the following? Select all that apply.
May we have permission to discuss your dental treatments with your spouse, parent, etc. if necessary?
Is there any information you would like to share with us to make your treatment more comfortable?
By signing below, I agree that I have answered the above questions truthfully and completely