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NEW PATIENT REGISTRATION FORM:

PATIENT’S NAME _________________________________________________ BIRTHDAY ________/________/________ AGE__________
ADDRESS___________________________________________________________HOME PHONE______________________________________
CITY________________________ STATE________ ZIP_________________CELL PHONE_______________________________________
EMPLOYER/OCCUPATION____________________________________________WORK PHONE______________________________________
DENTAL INSURANCE PLAN (if any)________________________________________________________________________________________
And WHOM MAY WE THANK FOR THIS REFERAL?___________________________________________________ We would like to say thanks!
________________________________________________________________________________________________________________________

DENTAL HISTORY
——————————————————————————————————————————————————————–————-—
FORMER DENTIST_____________________________________________________ DATE OF LAST EXAM_____________________________
WHAT CONCERNS YOU ABOUT YOUR TEETH?_____________________________________________________________________________
RATE YOURSELF ABOUT DENTAL VISITS: ___________ Calm __________ A bit nervous __________ Very nervous
DENTAL HISTORY: ________Periodontal Treatment ________Orthodontic Treatment ___________Frequency Brushing __________Flossing
________________________________________________________________________________________________________________________
MEDICAL HISTORY
——————————————————————————————————————————————————–———–—————––

PHYSICIAN’S NAME___________________________________ PHONE__________________________ DATE OF LAST VISIT_____________
ARE YOU PRESENTLY UNDER A PHYSICIAN’S CARE? ____________Yes ___________No
If YES, please explain ______________________________________________________________________________________________________
HAVE YOU EVER HAD A SERIOUS ILLNESS/ OPERATION, OR STILL HAVE ONE? _____________Yes ____________No
If YES, please explain ______________________________________________________________________________________________________
ARE YOU TAKING ANY MEDICATIONS OR SUPPLEMENTS? _______________Yes ____________No
If YES, please list _________________________________________________________________________________________________________
DO YOU HAVE ANY ALLERGIES TO MEDICATIONS OR DRUGS? _____Yes _____No If YES, list: ________________________________
HAVE YOU EVER TAKEN BONE DRUGS? (Fosamax, Evista, Actonel, Boniva, Reclast, others) _____________________Yes __________No
CHECK ANY THAT APPLY: ___________Allergies to Anesthetics ______Artificial Joints ______Artificial Heart Valve _______Hepatitis
_____High Blood Pressure _________Cancer ________Heart Problems _____Liver or Kidney Problems _____Tobacco Use ____Tuberculosis
________Immune Problems ________Bleeding Problems ____HIV Positive ____Taking Contraceptives ____Latex Allergy ______Diabetes
____Now Pregnant ________ Psychiatric or Emotional Problems ____Other, please explain____________________________________________
Thank you for choosing our office for your dental care!

I CERTIFY THAT THE ABOVE IS COMPLETE & ACCURATE:
Signature_____________________________________________________________ Date________/________/_______

Source: http://www.drplevine.com/New%20Patient%20Form.pdf

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