NEW PATIENT DENTAL REGISTRATION AND HISTORY Patient Information (confidential)
Today's Date *
SS/HIC/Patient ID #
Name *
Address *
Birth date *
Age *
Email
Sex Male
Female
Status Single Married Separated Divorced Minor
Patient Employer/School
Occupation
Employer/School Address
Employer/School Phone
Spouse's Name
Spouse's Birth Date
Spouse's SS#
Spouse's Employer
Whom may we thank for referring you?
Dental Insurance
Who is responsible for this account?
Relationship to Patient
Insurance Co.
Group #
Is patient covered by addtional insurance? Yes
No
If yes, Subscriber's Name
Birth date
SS#
Relationship to Patient
Insurance Co.
Group #
Phone Numbers
Home #
Work #
Cell #
Spouse's Work #
Best time and place to reach you
In case of emergency, contact
Relationship
Phone #
Dental History
Reason's for today's visit
Former Dentist
City/State
Date of last dental visit
Date of last dental X-rays
Place a mark to indicate if you have had any of the following:
Bad Breath
Bleeding Gums
Blisters on lips or mouth
Burning sensation on tongue
Chew on one side of mouth
Cigarette, pipe, or cigar smoking
Clicking or popping jaw
Dry mouth
Fingernail biting
Food collection between the teeth
Foreign objects
Grinding teeth
Gums swollen or tender
Jaw pain or tiredness
Lip or cheek biting
Loose teeth or broken fillings
Mouth breathing
Mouth pain, burshing
Orthodontic treatment
Pain around ear
Periodontal treatment
Sensitivity to cold, heat, or sweets
Sores or growths in your mouth
How often do you floss?
How often do you brush?
Health History
Physician's Name
Date of last visit
Place a mark to indicate if you have had any of the following:
AIDS/HIV
Anemia
Arthritis, Rheumatism
Artificial Heat Valves
Artificial Joints
Asthma
Back Problems
Bleeding abnormally with extracts or surgery
Blood Disease
Cancer
Chemical Dependency
Chemotherapy
Circulatory Problems
Congenital Heart Lesions
Cortisone Treatments
Cough, persistent or bloody
Diabetes
Emphysema
Epilepsy
Fainting or dizziness
Glaucoma
Headaches
Heart Murmur
Heart Problems
Hepatitis
High Blood Pressure
Jaundice
Jaw Pain
Kidney Disease
Liver Disease
Low Blood Pressure
Mitral Valve Prolapse
Nervous Problems
Pacemaker
Psychiatric Care
Radiation Treatment
Respiratory Disease
Rheumatic Fever
Scarlet Fever
Shortness of Breath
Sinus Trouble
Skin Rash
Special Diet
Stroke
Swollen Feet or Ankles
Swollen Neck Glands
Thyroid Problems
Tonsillitis
Tuberculosis
Tumor or growth on head or neck
Ulcer
Venereal Disease
Medications
List any medications you are currently taking and the correlating diagnosis:
Pharmacy Name
Phone Number
Allergies
Allergic to: Aspirin
Sleeping pills
Codeine
Iodine
Latex
Local Anesthetic
Penicillin
Sulfa
Other
Authorization
I affirm that the information I have given on this form is correct to the best of my knowledge and it is my responsibility to inform this office of any changes in my medical status. I authorize my insurance benefits to be paid directly to Dr. Lomonte. I understand that I am responsible for the payment of deductibles, co-payments, and any balances not covered by my insurance. I understand that payment is due at the time of service.
Electronic Signature (name)
Today's Date
Image Verification
