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contact
Home
about
patients
contact
Print PDF form:
Patient Registration Form (Print PDF)
OR
fill out the form below:
Name (First, Last)
*
Email
*
Preferred Name
Social Security (PLEASE PROVIDE WHEN CHECK-IN)
Birthdate
MM
DD
YYYY
Address
Home Phone
(###)
###
####
Cell Phone
(###)
###
####
Work Phone
(###)
###
####
Preferred Contact
Home
Cell
Email
Text
Work
Status
Minor
Single
Married
Widowed
School/College (if student)
School/College Address (if student)
Student Status
Full
Part-time
Patient's/Parent's Employer
Occupation
Work Phone
(###)
###
####
Spouse Name
Spouse Employer
Spouse Work Phone
(###)
###
####
Emergency Contact
Emergency Contact Phone Number
(###)
###
####
Whom May We Thank For Referral
RESPONSIBLE PARTY
Responsible Party Name
Relationship
Responsible Party Address
Responsible Party Phone Number
(###)
###
####
Responsible Party Driver's License
Responsible Party Birth Date
MM
DD
YYYY
Responsible Party Social Security Number (PLEASE PROVIDE WHEN CHECK-IN)
Responsible Party Employer
Responsible Party Employer Work Phone
(###)
###
####
INSURANCE INFORMATION
Subscriber Name
Subscriber Relationship
Subscriber Social Security Number (PLEASE PROVIDE WHEN CHECK-IN)
Subscriber Date of Birth
MM
DD
YYYY
Subscriber Employer
Insurance Company
Group Number
Insurance Phone Number
(###)
###
####
Insurance Address
SECONDARY INSURANCE
Insurance Company
Group Number
Insurance Phone Number
(###)
###
####
DENTAL HISTORY
Reason for visit
When was your last dental visit?
MM
DD
YYYY
Previous Dentist's Name
Date of last teeth cleaning
MM
DD
YYYY
Have you ever had an unfavorable experience in the dental office?
Yes
No
Does dental treatment make you nervous?
No
Slightly
Moderately
Extremely
For restorative fillings, please indicate your preference:
AMALGAM (silver)
COMPOSITE (white)
For crown or inlays, please circle your preference:
GOLD
PORCELAIN
Do you have any wisdom teeth?
Yes
No
Have any of your wisdom teeth been taken out?
Yes
No
Have you ever been treated for periodontal disease (gum disease, pyorrhea, trench mouth)?
Yes
No
If so, when?
MM
DD
YYYY
Do you have or have you ever had any of the following?
Bleeding, sore gums
Unpleasant taste/bad breath
Burning tongue/lips
Frequent blisters, lips/mouth
Swelling/lumps in mouth
Ortho treatments (braces)
Biting cheeks/lips
Clicking/popping jaw
Difficulty opening or closing jaw
Loose teeth
Sensitive to hot
Sensitive to cold
Sensitive to sweets
Sensitive to biting
Food impaction
Clenching/grinding
Shifting of teeth
Change in bite
ORAL HYGIENE
How many times a day do you brush?
Your tooth brush is
Soft
Medium
Hard
How many times a day do you floss?
How often do you use fluoride rinse?
Do you have other oral hygiene practices?
MEDICAL HISTORY
Physician's Name
Clinic Name
Phone
(###)
###
####
Date of Last Medical Examination
MM
DD
YYYY
Are you under medical treatment now?
Yes
No
If yes, what is the condition?
Have you ever been hospitalized for any surgical operations or serious illness?
Yes
No
If yes, please explain
Have you ever had excessive bleeding following an injury?
Yes
No
Do you smoke or use tobacco products?
Yes
No
If yes, how often?
Are you allergic to or have you had any reaction to the following:
Local Anesthetic (Novocaine)
Penicillin or Other Antibiotics
Sulfa Drugs
Sedatives
Iodine
Aspirin
Codeine
Other (please identify below)
Other allergies
Check any of the following which you have had or have at present:
AIDS or HIV Infection
Anemia
Angina
Anxiety
Artificial Heart Valve
Artificial Joints (knee, hip)
Arthritis
Asthma
Auto-immune Disease
Bulimia
Cataracts/Glaucoma
Chemical Dependency
Chemotherapy
Chronic Fatigue Syndrome
Convulsions
Depression
Dieting Concerns
Dizziness
Epilepsy
Emphysema
Fainting
Hay Fever
Heart Disease
Heart Murmur
Hemophilia (Bleeding Disorder)
Hepatitis A (Infectious)
Hepatitis B (Serum)
Hepatitis C
Jaundice
Kidney Disease
Liver Disease
Lupus
Mitral Valve Prolapse
Neurological Disorders
Pacemaker / Defibrillator
Psychiatric Care
Radiation Treatment
Rheumatic /Scarlet Fever
Sickle Cell Anemia
Sinus Infections
Thyroid Disorder
Tuberculosis
Venereal Disease
Blood Pressure (indicate if applicable)
Low
High
Blood Transfusion (indicate date if applicable)
MM
DD
YYYY
Cancer (specify type if applicable)
Diabetes Type (if applicable)
Headaches (most recent date if applicable)
MM
DD
YYYY
Heart Attack (date if applicable)
MM
DD
YYYY
Stroke (date if applicable)
MM
DD
YYYY
Ulcer (specify if applicable)
Is Pre-medication Necessary?
Yes
No
If Yes, why?
Are you taking any of the following?
Appetite Suppressants
Aspirin
Diet Supplements
Garlic
Ginkgo Biloba
Ginseng
Motrin/Advil (Ibuprophen)
St. Johns Wort
Bisphosphonates for osteoporosis & cancer
Fosamax
Boniva
Actonel
Zometa
Aredia
Ostac
Skelid
Didronel
Other medications, supplications or over-the-counter products not listed above
Please provide any other medical information not listed above
I hereby certify that the above information is true and correct to the best of my knowledge. If I ever have any change in my health or medication, I will inform Dr. Sperry and her staff at the next appointment.
*
Date
*
MM
DD
YYYY
OUR OFFICE POLICY
Our office is committed to providing you with the best quality of dental care. In order to achieve this goal, we need your cooperation as well as your understanding of this payment policy. Payment for services is due at the time the care is provided, unless other arrangements are made with our Business Manager. For your convenience we offer the following methods of payments: Cash, Checks, Visa, MasterCard, Discover, and American Express. A fee of $35.00 will be assessed on any returned check. CANCELLATION POLICY: A charge of $75.00/hr is made for broken or cancelled appointments without 48 hours notice (excluding weekends and holidays).
Patient Initials
*
PATIENT RESPONSIBILITIES REGARDING DENTAL INSURANCE
If you have dental insurance, we will gladly submit claims for you; provided we are given complete and accurate insurance information, as well as a release of benefits and information to your insurance company. We can estimate your insurance benefits for you; however we cannot guarantee payments. These estimates are based on your exams & x-rays. Changes in proposed treatment may need to be made due to clinical considerations. Your dental insurance is a contract between you and your insurance company; it is your responsibility to be aware of annual maximums and contract limitations. You are responsible for payment for services received from Dr. Sperry in accordance with the office regular fees and terms. Your responsibility is not modified by whether any third party (insurance) pays for all, part, or none of the charges.
Patient Initials
*
AUTHORIZATION AND RELEASE
PERMIT FOR TREATMENT AND/OR SURGICAL CARE: I hereby grant permission to Dr. Sperry, or her assignee, to employ such established treatments and therapy as may be deemed professionally necessary and advisable. FINANCIAL AGREEMENT: All charges for services and treatment will be paid upon completion of appointment. I understand that this account becomes delinquent if not paid within 60 days after billing and that at this time a Finance Charge of 1.5% (18% per annum) per month will be applied on the unpaid balance. In the event of default, I agree to pay all legal indebtedness together with such collection costs if suit be instituted hereunder. I authorize all credit inquiries deemed necessary in connection with my account. INSURANCE: I hereby authorize payment directly to Dr. Sperry, the dentist, otherwise payable to me.
Signature of patient/parent/guardian
*
Date
*
MM
DD
YYYY
Thank you!
