Creek View Dental

    Welcome: The benefits of good oral health are endless, and we want to help you obtain and maintain a happy, healthy smile. Please fill out this form as completely as you can. The more we know about you, the better we can take care of you. Thank you.

     

    Patient Registration



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    SingleMarriedDivorcedWidowedSeparated








     

    Contact / Reminder Preference:

    Home phoneWork phoneCell phoneEmail





     

    Spouse Information




     

    In the Event of An Emergency, We Should Contact:



     

    Person Responsible for Account Same as Patient____








     

    Dental Insurance—Primary









     

    Dental Insurance—Secondary








     

    Dental History


    Are you having pain or discomfort? YesNo
    Have you experienced problems with previous dental work? YesNo

    Are you apprehensive about going to the dentist? YesNo
    My current dental health is: GoodFairPoor
    Do your gums ever bleed? YesNo
    Have you ever received treatment for periodontal disease? YesNo
    Are any of your teeth lose? YesNo
    Have you lost any adult teeth? YesNo

    Are any of your teeth especially sensitive to temperature? YesNo
    Are any of your teeth sensitive to chewing? YesNo
    Are any of your teeth sensitive to sweet things? YesNo
    Do you clench your teeth? Grind your teeth? YesNo
    Are you happy with the way your smile looks: YesNo



     

    Medical History

    Are you currently under a physician's active care? YesNo
    Have you had a medical condition or accident requiring hospitalization in the past 3 years? YesNo





    Do you smoke or use tobacco in any form? YesNo

     

    Review of Symptoms

    AIDS/HIV Positive: Have NowHad in PastNever had Excessive Bleeding: Have NowHad in PastNever had
    Mitral Valve Prolapse: Have NowHad in PastNever had Alzheimer's Disease:  Have NowHad in PastNever had
    Excessive Thirst: Have NowHad in PastNever had Pain in Jaw Joints: Have NowHad in PastNever had
    Anemia: Have NowHad in PastNever had Fainting Spells/ Dizziness: Have NowHad in PastNever had
    Parathyroid Disease: Have NowHad in PastNever had Angina: Have NowHad in PastNever had
    Frequent Cough: Have NowHad in PastNever had Psychiatric Care: Have NowHad in PastNever had
    Arthritis/ Gout: Have NowHad in PastNever had Frequent Headaches: Have NowHad in PastNever had
    Radiation Treatments: Have NowHad in PastNever had Artificial Heart Valve: Have NowHad in PastNever had
    Glaucoma: Have NowHad in PastNever had Recent Weight Loss: Have NowHad in PastNever had
    Artificial Joint: Have NowHad in PastNever had Hay Fever: Have NowHad in PastNever had
    Renal Dialysis: Have NowHad in PastNever had Asthma: Have NowHad in PastNever had
    Heart Attack/ Failure: Have NowHad in PastNever had Rheumatic Fever: Have NowHad in PastNever had
    Blood Disease: Have NowHad in PastNever had Heart Murmur: Have NowHad in PastNever had
    Rheumatism: Have NowHad in PastNever had Blood Transfusion: Have NowHad in PastNever had
    Heart Pacemaker: Have NowHad in PastNever had Scarlet Fever: Have NowHad in PastNever had
    Breathing Problem: Have NowHad in PastNever had Heart Trouble/ Disease: Have NowHad in PastNever had
    Shingles: Have NowHad in PastNever had Bruise Easily: Have NowHad in PastNever had
    Hemophilia: Have NowHad in PastNever had Sickle Cell Disease: Have NowHad in PastNever had
    Cancer: Have NowHad in PastNever had Hepatitis B or C: Have NowHad in PastNever had
    Sinus Trouble: Have NowHad in PastNever had Chemotherapy: Have NowHad in PastNever had
    Herpes: Have NowHad in PastNever had Stomach/ Intestinal Disease: Have NowHad in PastNever had
    Chest Pains: Have NowHad in PastNever had High Blood Pressure: Have NowHad in PastNever had
    Stroke: Have NowHad in PastNever had Cold Sores/ Fever Blisters: Have NowHad in PastNever had
    Hives or Rash:  Have NowHad in PastNever had Swelling of Limbs: Have NowHad in PastNever had
    Congenital Heart Disorder: Have NowHad in PastNever had Hypoglycemia: Have NowHad in PastNever had
    Thyroid Disease: Have NowHad in PastNever had Convulsions: Have NowHad in PastNever had
    Irregular Heartbeat: Have NowHad in PastNever had Tuberculosis: Have NowHad in PastNever had
    Cortisone Medicine: Have NowHad in PastNever had Kidney Problems:  Have NowHad in PastNever had
    Tumors or Growths: Have NowHad in PastNever had Diabetes: Have NowHad in PastNever had
    Leukemia: Have NowHad in PastNever had Ulcers: Have NowHad in PastNever had
    Drug Addiction: Have NowHad in PastNever had Liver Disease: Have NowHad in PastNever had
    Venereal Disease: Have NowHad in PastNever had Emphysema:  Have NowHad in PastNever had
    Low Blood Pressure: Have NowHad in PastNever had Yellow Jaundice: Have NowHad in PastNever had
    Epilepsy or Seizures: Have NowHad in PastNever had Lung Disease: Have NowHad in PastNever had

     

    For Women

    Are you pregnant now? YesNo

    Are you nursing?  YesNo

    Current Medications

    Are you currently taking ANY medications or drugs : (prescription, OTC : YesNo
    If so, please list medications and purpose:  

    Do you require antibiotic premedication prior to dental treatment for things such as a heart valve or a joint replacement?  YesNo

    Allergies

    Are you allergic to or had an unfavorable reaction to any of the following? PenicillinOther AntibioticsCodeineAspirinIbuprofen/Advil/MotrinNovocaine/local anestheticsOther drugs or medicationsLatexMetalsAcrylic
    Please list any other allergies you may have:  

    I understand that the information I have given today is correct to the best of my knowledge. I understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. Agree:  YesNo
    Dated:

    I understand that all responsibility for payment for dental services provided in this office for myself and/or my dependents is mine, due, and payable at the time services are rendered unless other arrangements have been made. In the event payments are not received by the agreed-upon dates, I understand that a 11⁄2% finance charge (18% APR) may be added to my account and that expenses incurred to collect a delinquent payment will be added to the account due. Agree: YesNo
    Dated: