Tri Lakes Dental - Registration

Welcome to online registration form

Completing this registration form online allows you to simply walk in and sign your paperwork electronically.

All information submitted through our secure online patient registration form is strictly confidential and will only be used by our office staff to ensure that you receive the highest level of care available.

PATIENT INFORMATION

DENTAL INSURANCE

Date:

Who is responsible for this account?

Patient:

Relationship to patient?

Address:

Insurance Company?

City:

Group Number:

State:

Zip:

Is patient covered by additional insurance?

Yes

Sex:

Male

Female

Subscriber's Name:

Age:

Birthdate:

SS#

Single

Married

Widowed

Relationship to patient?

Separated

Divorced

Insurance Company?

Patient SS#

Group Number:

Occupation:
Employer:
Employer Address:
Employer Phone:
Spouse's Name:
Spouse's Birthdate:
Spouse's SS#:
Occupation
Spouses Employer:

ASSIGNMENT AND RELEASE

I, the undersigned certify that I (or my dependent) have insurance coverage with and assign directly to Dr. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

Responsible Party Signature:

Relationship:

Date:

Whom may we thank for referring you?

PHONE NUMBERS

Home:

Work:

Ext.

Spouse's Work:

Best time and place to reach you?

IN CASE OF EMERGENCY, CONTACT (Specify Someone who does not live in your household.)

Name:

Relationship:

Home Phone:

Work Phone:

DENTAL HISTORY

Reasons for today's visit?

Former Dentist:

City/State:

Date of last dental visit:

Click "Yes" to indicate if you have had any of the following. Leave blank if you have not.

Bad Breath	Yes
Bleeding Gums	Yes
Blisters on lips or mouth	Yes
Burning Sensation on tongue	Yes
Chew on one side of mouth	Yes
Cigarette, pipe, or cigar smoking	Yes
Clicking or popping jaw	Yes
Dry mouth	Yes
Fingernail biting	Yes
Food collection between the teeth	Yes

Foreign objects	Yes
Grinding teeth	Yes
Gums swollen or tender	Yes
Jaw pain or tiredness	Yes
Lip or cheek biting	Yes
Loose teeth or broken fillings	Yes
Mouth breathing	Yes
Mouth pain, brushing	Yes
Orthodontic treatment	Yes
Pain around ear	Yes
Periodontal treatment	Yes
Sensitivity to cold	Yes
Sensitivity to heat	Yes
Sensitivity to sweets	Yes
Sensitivity when biting	Yes
Sores or growths in your mouth	Yes
How often do you floss?
How often do you brush?

What kind of dental experiences have you had in the past?

Good Bad Average

Please explain below if you wish.

How do you feel about the general condition of your teeth?

Poor

Great

Please explain below if you wish.

How important is it for you to keep your teeth in optimal health, comfort and esthetics?

Not Important

Very Important

Please explain below if you wish.

Do you consume one or more soft drinks per day?

Yes No

How satisfied are you with the appearance of your smile?

Not Satisfied

Very Satisfied

What would you change if there were no obstacles?

Would you be interested in hearing about cosmetic options to whiten or improve your smile?

Yes No

HEALTH HISTORY

AIDS	Yes
Anemia	Yes
Arthritis, Rheumatism	Yes
Artificial Heart Valves	Yes
Artificial Joints	Yes
Asthma	Yes
Back Problems	Yes
Bleeding abnormally, with extractions or surgery	Yes
Blood Disease	Yes
Cancer	Yes
Chemical Dependency	Yes
Chemotherapy	Yes
Circulatory Problems	Yes
Congenital Heart Lesions	Yes
Cortisone Treatments	Yes
Cough, persistent, or bloody	Yes
Diabetes	Yes
Emphysema	Yes
Do you wear contact lenses?	Yes
Epilepsy	Yes
Fainting or Dizziness	Yes
Glaucoma	Yes
Headaches	Yes
Heart Murmer	Yes
Heart Problems	Yes
Hepatitis Type:
Herpes	Yes
High Blood Pressure	Yes
HIV Positive	Yes

Jaundice	Yes
Jaw Pain	Yes
Kidney Disease	Yes
Liver Disease	Yes
Low Blood Pressure	Yes
Mitral Valve Prolapse	Yes
Nervous Problems	Yes
Pacemaker	Yes
Women: Are you pregnant?	Yes
Due Date?
Are you nursing?	Yes
Psychiatric Care	Yes
Radiation Treatment	Yes
Respiratory Disease	Yes
Rheumatic Fever	Yes
Scarlet Fever	Yes
Shortness of Breath	Yes
Sinus Trouble	Yes
Skin Rash	Yes
Special Diet	Yes
Stroke	Yes
Swelling of Feet or Ankles	Yes
Swollen Neck Glands	Yes
Thyroid Problems	Yes
Tonsilitis	Yes
Tuberculosis	Yes
Tumor or growth on head or neck	Yes
Ulcer	Yes
Venereal Disease	Yes
Weight Loss Unexplained	Yes

MEDICATIONS

ALLERGIES

List medications you are currently taking:

Pharmacy Name:

Pharmacy Phone:

Aspirin	Yes
Barbituates (sleeping pills)	Yes
Codeine	Yes
Iodine	Yes
Latex	Yes
Local Anesthetic	Yes
Penicillin	Yes
Sulfa	Yes
Other