New Patient Registration Form | JP Prosthedontics

1Patient Information

2Insurance Information

3Dental History

4Medical History & Authorization

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This field is for validation purposes and should be left unchanged.

First Name(Required)

Middle Name

Last Name(Required)

Date of Birth(Required)

Gender(Required)

Male

Female

Best Number to Reach You(Required)

Please Check One(Required)

Home

Work

Cell

Other

Secondary Phone Number

Email(Required)

Emergency Contact(Required)

Relation to You(Required)

Phone Number(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Marital Status(Required)

Minor

Single

Married

Divorced

Widowed

Social Security Number(Required)

Whom may we thank for referring you?

Primary Carrier(Required)

Claims Mailing Address(Required)

Employer(Required)

Please put N/A if not applicable.

Employee Name(Required)

Please put N/A if not applicable.

Relation to Patient(Required)

Date of Birth(Required)

Member ID(Required)

Group Number(Required)

Secondary Carrier

Claims Mailing Address

Employer

Please put N/A if not applicable.

Employee Name

Please put N/A if not applicable.

Relation to Patient

Date of Birth

Member ID

Group Number

Please note that the above information regarding your dental insurance is most important to our billing office. Please be certain that all information is complete as misinformation can result in unnecessary delay in insurance reimbursement. Also, please remember that you, as the patient, are solely responsible for the services rendered, regardless of your insurance coverage. If for some reason we have not received payment from your insurance carrier within 60 days, we expect you to personally settle the outstanding balance within 30 days.

Reason for Today's Visit(Required)

Date of Last Dental Visit/ Dental X-Ray?

How often do you brush?

How often do you floss?

Please select if you have (or had) any of the following:

Bad Breath or Dry Mouth

Grinding

Bleeding Gums

Clicking/ Popping Jaw

Loose Teeth or Broken Fillings

Braces

Gum Disease/ Treatment

Food Collection Between Teeth

Sores or Growths in your Mouth

Teeth Sensitivity to Cold, Heat, Sweets, or Biting

How do you feel about your smile?

Are you experiencing any dental pain or discomfort?

Please Select All that Apply

AIDS/ HIV Positive

Alzheimer's Disease

Anaphylaxis

Anemia

Angina

Arthritis/ Gout

Artificial Heart Valve

Artificial Join

Asthma

Blood Disease

Blood Transfusion

Breathing Problems

Bruise Easily

Cancer

Chemotherapy

Chest Pains

Cold Sores Fever Blisters

Congenital Heart Disorder

Convulsions

Diabetes

Drug Addiction

Emphysema

Epilepsy or Seizures

Excessive Bleeding

Excessive Thirst

Fainting Spells/ Dizziness

Frequent Cough

Frequent Headaches

Glaucoma

Hay Fever

Heart Attack/ Failure

Heart Murmur

Heart Pacemaker

Heart Trouble/ Disease

Hemophilia

Hepatitis A

Hepatitis B or C

Herpes

High Blood Pressure

High Cholesterol

Hives or Rash

Hypoglycemia

Irregular Heartbeat

Kidney Problems

Leukemia

Liver Disease

Low Blood Pressure

Lung Disease

Mitral Valve Prolapse

Osteoporosis

Pain in Joints

Psychiatric Care

Radiation Treatments

Recent Weight Loss

Renal Dialysis

Rheumatism

Scarlet Fever

Shingles

Sickle Cell Disease

Sinus Trouble

Stomach/ Intestinal Disease

Stroke

Swelling of Limbs

Thyroid Disease

Tonsilitis

Tuberculosis

Tumor or Growths

Ulcers

Venereal Disease

Has a physician or dentist recommended you take antibiotics prior to your dental visit?(Required)

Yes

Artificial (prosthetic) heart valve?(Required)

Yes

Damaged valves in transplanted heart?(Required)

Yes

Previous infective endocarditis?(Required)

Yes

Congenital heart disease?(Required)

Yes

Have you had any serious illness or operation?(Required)

Yes

If yes, please explain:

Are you taking any medications?(Required)

Yes

If yes, please list them here:

Have you ever taken Fosamax, Bonita, Actonel or anu other medications containing bisphosphonate for osteoporosis?(Required)

Yes

Are you currently under a physicians care?(Required)

Yes

If yes, please explain:

Have you ever had a serious head or neck injury?(Required)

Yes

If yes, please explain:

Are you on a special diet?(Required)

Yes

If yes, please explain:

Do you use tobacco or cannabis?(Required)

Yes

Do you use controlled substances?(Required)

Yes

Women: Please select all that apply

Pregnant/ Trying to get pregnant

Taking contraceptives

Nursing

Are you allergic to any of the following?

Latex

Metal

Barbiturates, sedatives or sleeping pills

Penicillin/ Antibiotics

Aspirin

Acrylic

Sulfa Drugs

Iodine

Local Anesthetics

Codeine/ Narcotics

Other

Payment is due in full at the time of treatment unless prior arrangements have been approved.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form. I authorize and request my insurance company to pay directly to the dentist or dental group in insurance benefits otherwise payable to me. I authorize the doctor to release all information necessary to secure the payments of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of this signature on all insurance submissions.

Initials(Required)

Signature

Your Name
Your Name
Your Name

Date(Required)