Patient Registration Form - Pacifica Dental

Patient Information

*All fields required

Salutation*

First Name*

Last Name*

Date of Birth*

Registering for a child?*

Yes
No

Person responsible for account*

Other parental consent required*

Yes
No

Mother’s name*

Business Tel*

Father’s name*

Business Tel*

Contact Information

Email*

Home Phone*

Cell Phone*

Work Phone*

Address*

Street Address City Province Postal Code

In case of emergency, please notify:

Name*

Relation*

Home Phone*

Cell Phone*

Work Phone*

Contact Options

I prefer appointment reminders by*

Phone
SMS (TEXT)
Email

Whom may we thank for referring you?*

Are any other members of your family patients at our practice?*

Yes
No

Please list all family members*

Insurance Information*

Yes, insurance applies to me
No, insurance does not apply to me

Please complete the following if you have dental insurance

Name of insured/subscriber*

Date of Birth*

Patient's relationship to subscriber*

Self
Spouse
Child

Place of Employment*

Insurance Company*

Policy/Group #*

Certificate/ID #*

I authorize release to my dental benefits plan administrator information contained in claims and/or predeterminations*

Yes

Medical History

The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by Doctor/Patient confidentiality. The Dentist will review the questions and explain any that you do not understand. Please complete the entire form.

Are you being treated for any medical condition at the present or any time within the past year?*

Yes
No
Not Sure/Maybe

When was your last medical checkup?*

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

Yes
No
Not Sure/Maybe

Please Specify*

Are you taking any prescription, non-prescription medications, or herbal supplements?*

Yes
No
Not Sure/Maybe

Please list and provide dosages. If there is insufficient room, please bring a written list of all your medications to your first appointment.

Do you have any allergies?*

Yes
No
Not Sure/Maybe

--select--*

Have you ever had a peculiar or adverse reaction to any medicines or injections?*

Yes
No
Not Sure/Maybe

Please list below with approximate dates*

Do you have or have you ever had asthma?*

Yes
No
Not Sure/Maybe

Do you have or have you ever had any heart or blood pressure problems?*

Yes
No
Not Sure/Maybe

Do you have or have you ever had an artificial heart valve, infection of the heart (i.e. #infective endocarditis), a heart condition from birth (i.e. congenital heart disease), or a heart transplant?*

Yes
No
Not Sure/Maybe

Do you have a prosthetic or artificial joint?*

Yes
No
Not Sure/Maybe

Do you have any conditions which may affect your immune system (i.e. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?*

Yes
No
Not Sure/Maybe

Please specify*

Have you ever had hepatitis, jaundice, or liver disease?*

Yes
No
Not Sure/Maybe

Do you have a bleeding problem or bleeding disorder?*

Yes
No
Not Sure/Maybe

Please specify*

Have you ever been hospitalized for any illnesses or operations?*

Yes
No
Not Sure/Maybe

Please specify*

Do you have, or have ever had any of the following? Please check*

Are there any conditions/diseases not listed that you have or have had?*

Yes
No
Not Sure/Maybe

If yes, please specify:*

Are there any diseases/medical problems that run in your family (e.g. diabetes, cancer, heart disease, etc.)?*

Yes
No
Not Sure/Maybe

If yes, please specify:*

Do you smoke or chew tobacco products?*

Yes
No
Not Sure/Maybe

Are you nervous during dental treatment?*

Yes
No
Not Sure/Maybe

For women only: Are you pregnant or breastfeeding?*

Yes
No
Not Sure/Maybe

What is your expected delivery date?*

Dental History

Do you have any specific dental concerns? Please list:*

When was your last dental appointment?*

How often do you see the dentist?*

Is there anything about the appearance of your teeth that you would like to change?*

Have you ever whitened (bleached) your teeth?

Yes
No
Not Sure/Maybe

Do you feel uncomfortable or self-conscious about the appearance of your teeth?*

Have you been disappointed with the appearance of previous dental work?

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