Patient Registration Form for Terry Family Dentistry

First Name *

Last Name *

Middle Initial

Date of Birth *

Email *

Home Phone

Mobile Phone

Address *

Address Line 2

City *

State *

ZIP Code

Country *

Sex *

Status *

SSN

Employer Info

Employer

Name of Business

Phone

Work Phone

Employer Address

Employer City

Employer State

Employer ZIP Code

Who should we thank for referring you?

Referrer Full Name

Referrer Phone

Referrer Address

Referrer Address Line 2

Referrer City

Referrer State

Referrer ZIP Code

In Case of Emergency, who should we contact?

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Relationship

Who Is responsible for this Account Balance?

Relationship

DENTAL INSURANCE Subscriber Information

Primary Insured/Subscriber

Last Name

Primary Insured/Subscriber

First Name

Primary Insured/Subscriber

Middle Initial

Date of Birth

SSN

Relationship to Patient

Subscriber Home Phone

Subscriber Mobile Phone

Subscriber Work Phone

Subscriber Address

Subscriber City

Subscriber State

Subscriber ZIP Code

Dental Insurance Co. Name

Dental Insurance Co. Phone

Please tell us what brings you to us today?

What concerns you most about your teeth?

DENTAL HISTORY

Date of Last dental visit

Date of Last Dental X ‐ Rays

How often do you Brush/Floss?

Have you ever had any type of reaction to dental treatment or anesthetics?

Please check all conditions that you want Dr. Terry to check out

MEDICAL HISTORY

Your Physician’s Name

Your Physician’s Address

Your Physician’s Phone

Are you currently under the care of this Physician?

Do you have any serious illnesses?

Please describe

What medications do you currently take?

Please list all medications

Do You Smoke?

Do You Drink Alcohol?

Do You use other drugs?

Are you Pregnant?

Have you ever had any allergic reaction to any medicine or dental procedure?

Please describe and list all allergies

Please check all that apply

Is there anything else we should know about your medical health?

Patient Registration

Quick Contact Form

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