New Patient Registration Form Leave this field blank Status: Child Married Single Widowed Divorced Whom may we thank for your referral? Google Flyer Website Other Are you aware of having an allergic (or adverse) reaction to any medication or substance? Yes No Have you been under the care of a medical doctor during the past two years? Yes No Indicate which of the following you have had, or presently have: (optional) Heart (Surgery, Disease, Attack) Congenital Heart Disease Glaucoma Emphysema Chronic Cough Tuberculosis Asthma Radiation Therapy Hepatitis Liver Disease Stomach Ulcers Nervous/Anxious Venereal Disease Chest Pain Artificial Heart Valve Thyroid Problems Mitral Valve Prolapse A.I.D.S. Heart Pacemaker Hemophilia Rheumatic Fever Cortisone Medicine Psychiatric/Psychological Care Sickle Cell Disease Swollen Ankles Kidney Trouble Yellow Jaundice Stroke Have you ever needed Premed prior to dental treatment? Tumors Are you taking blood thinners? Bruise Easily Chemotherapy Arthritis/Rheumatism Neurological Disorders Do you smoke? Allergies or Hives Epilepsy or Seizures Sinus Trouble Diabetes Fainting or Dizzy Spells Cholesterol None of these options Have you recently had any of the following: Chicken Pox Strep Throat Measles Tonsilitis Mumps FOR WOMEN (optional) Are you pregnant? Yes No Are you nursing? Yes No Are you taking birth control? Yes No Have you ever had a serious illness or had been hospitalized? If so, explain: Do you have, or have you had any medical conditions not listed? Yes No Current Medication Lists: What can we do to make YOU smile? Check all that apply. Veneers/Crowns Correct Misaligned Teeth TMJ/Night Guard Sedation Dentistry Broken/Cracked Teeth Sports Guards Replace Metal Fillings Dental Implants Whitening Replace Missing Teeth Are you apprehensive about dental treatment? Yes No Do you have previous dental crowns? Yes No Have you had problems with previous dental treatment? Yes No Does the saliva in your mouth seem too much? Yes No Do you gag easily? Yes No Have you had orthodontic (braces) treatment? Yes No Do you wear dentures? Yes No Does food catch between your teeth? Yes No Have you ever noticed a slow-healing sore in your mouth? Yes No Do you have difficulty chewing your food? Yes No Do you experience pain when you chew? Yes No Do you avoid brushing any part of your mouth because of pain? Yes No Do you have Temporomandibular Jaw Disorder (TMD)? Yes No Are your teeth sensitive to cold? Yes No Do you clench or grind your jaws frequently? Yes No Are your teeth sensitive to heat? Yes No Are you satisfied with the appearance of your teeth? Yes No Are your teeth sensitive to sweets? Yes No Do you experience headaches or migraines? Yes No Are your teeth sensitive to sours? Yes No Do you notice an unpleasant taste or odor in your mouth? Yes No Do your gums bleed when you brush or floss? Yes No Do you have sleep problems? Yes No Do you have previous dental implants? Yes No Treatment ConsentI, the undersigned, authorize Warden Lebovic to perform any necessary dental services and oral surgery that I may need during my diagnosis and treatment with my informed consent. I certify that the medical and dental histories provided are accurate and complete to the best of my knowledge. I also understand that any and all dental services are my sole responsibility and that I should make myself aware of any fees associated with my dental care prior to treatment. I also acknowledge that there is no expressed, implied or guarantee of any procedure or dental treatment provided. Full Name Send
