Creek View Dental

Patient Registration

MaleFemale
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

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:

Submit