Patient Form Dental office, New Prague MN

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Thank you for selecting Dental On First!
We will strive to provide you with the best possible dental care. To help us meet your dental healthcare needs, please fill out this form completely in ink. If you have any questions or need assistance, please ask us – we will be happy to help

We offer a 5% discount on payment in full for same day services.

Please download, and print, our Patient Registration form. Fill it out, and bring with you to your appointment.

NEW PATIENT REGISTRATION FORM

Marital Status

If Student, Name of School/College

Patient’s or Parent’s Employer

Spouse or Parent’s Name

Whom May We Thank for Referring You?

Person to Contact in Case in Emergency

Name of Person Responsible for this Account

Relationship to Patient

Is this Person Currently a Patient in our Office?

Yes No

Insurance Information

Relationship to Patient

How Much is your Deductible?

How Much Have You Used?

DO YOU HAVE ADDITIONAL INSURANCE? IF YES, COMPLETE THE FOLLOWING:

Relationship to patient

How Much is your Deductible?

How Much Have You Used?

Patient Medical History

1. Check Appropriate Box

Yes No

2. Have you ever been hospitalized for any surgical operation or serious illness ?

Yes No

If yes, please explain

3. Are you taking any medication(s) including non-prescription medicine?

Yes No

If yes, please list all medication(s) you’re taking including any herbal supplements.

4. Have you ever taken Phen-Fen/Redux?

Yes No

5. Do you use tobacco ?

Yes No

6. Do you use controlled substances?

Yes No

7. Do you have or have you had any of the following?

High blood pressure

Yes No

Heart Disease

Yes No

Cardiac Pacemaker

Yes No

Easily Winded

Yes No

Rheumatic Fever

Yes No

Swollen Ankles

Yes No

Hay Fever/Allergies

Yes No

Fainting/Seizures

Yes No

Frequently Tired

Yes No

Radiation Therapy

Yes No

Low Blood Pressure

Yes No

Epilepsy/Convulsions

Yes No

Recent Weight Loss

Yes No

Liver Disease

Yes No

Joint Replacement

Yes No

Heart Trouble

Yes No

Kidney Disease

Yes No

Hepatitis/Jaundice

Yes No

Respiratory Problems

Yes No

AIDS or HIV Infection

Yes No

Mitral Valve Prolapse

Yes No

Thyroid Problem

Yes No

Stomach Troubles/Ulcers

Yes No

Patient Dental History

Name of Previous Dentist and Location

Why did you leave this Dentist?

1. Do your gums bleed while brushing and flossing?

Yes No

8. Do you have frequent headaches?

Yes No

2. Are your teeth sensitive to hot or cold liquids/foods?

Yes No

9. Do you clench or grind your teeth?

Yes No

3. Are your teeth sensitive to sweet or sour?

Yes No

10. Do you bite your lips or cheeks?

Yes No

4. Do you feel pain to any of your teeth?

Yes No

11. Have you had any difficult extractions in the Past ?

Yes No

5. Do you have any sores or lumps in or near your mouth?

Yes No

12. Have you any prolonged bleeding following extractions ?

Yes No

7. Have you ever experienced any of the following problem in your jaw?

13. Have you had orthodontic treatment

Yes No

Pain (joint, ear, side of face)?

Yes No

14. Do you wear dentures or partials

Yes No

Difficulty in opening or closing?

Yes No

15. Have you ever received oral hygiene instructions ?

Yes No

Difficulty in chewing?

Yes No

16. Do you like your smile?

Yes No

If not, what would you change?

Yes No

Authorization and Release

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be harmful to my health. I authorize the dentist to release any information rendered to me or my child during the period of such dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependants.

Signature of patient (or parent if minor)

At Dental on First, our aim is that every patient should leave smiling. And our dental team is highly knowledgeable, professionally skilled, and expertly trained to use state-of-the-art equipment and techniques to produce healthy and beautiful smiles for you.

Patient Form

Welcome

Please download, and print, our Patient Registration form. Fill it out, and bring with you to your appointment.

NEW PATIENT REGISTRATION FORM

Patient Information

Responsible Party

Insurance Information

DO YOU HAVE ADDITIONAL INSURANCE? IF YES, COMPLETE THE FOLLOWING:

Patient Medical History

Patient Dental History

Authorization and Release