For patients

Patient Registration Form

Are you filling this form out for yourself or someone else?

Myself Someone else

Patient info*

First Name

Preferred name

Last Name

Date of Birth*

Gender*

Male Female Decline

Status*

How did you hear about us?

Contact information*

Mailing Address

City

State

ZIP Code

Home Phone

Mobile Phone*

Do you have an emergency contact? *

Yes No

If yes,

Emergency Contact Name

Emergency Contact Phone

Relationship

Medical History

Any other conditions you feel are relevant?

Are you currently taking any medications or supplements? *

Yes No

If yes,

Any other medications we should know about?

Do you have any allergies you are aware of? (e.g., drug or latex allergies) *

yes No

If yes,

Are you pregnant or think you may be pregnant? *

Yes No

Are you nursing?*

Yes No

Do you use any recreational drugs?

Yes No Quit

Do you smoke/vape/chew tobacco?

Yes No Quit

Do you use marijuana?

Yes No Quit

Do you drink alcohol?

Yes No Quit

Do you have a primary care physician?*

Yes No

If yes,

Physician’s name and location

Has there been any change in your general health in the past year?

Yes No

Do you currently have any pain in our jaw or face?

Yes No

Have you had a serious illness or hospitalization in the past five years?

Yes No

Have you had any past surgeries?

Yes No

Does your physician recommend you take antibiotics prior to surgery due to a medical condition?

Yes No

Have you or anyone in your family had a problem with anesthesia?

Yes No

Have you ever taken a bone density medication like Fosamax or Bovina?

Yes No

Patient or Guardian Signature*

I certify that the information provided is accurate to the best of my knowledge.

We offer comprehensive services in Oral Medicine and Orofacial pain that are provided in a patient-friendly environment.

Patient Registration Form

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