Please Fill out the information below, print, and bring to your first appointment!

Dental Registration and History
Patient Information  
Date: Monday 6th of February 2012
SS/HIC/Patient ID#:
Patient's Last Name:
Patient's First Name:
Patient's Middle Initial:
Address:
E-Mail:
City:
State:
Zip:
Sex: Male Female
Age:
Birthdate:
Married Widowed Single Minor Separated Divorced
Partnered for years        
Patient Employer/School:
Occupation:
Employer/School Address:
Employer/School Phone:
Spouse's Name:
Birthdate:
SS#:
Spouse's Employer:
Whom may we thank for referring you?
   
Dental Insurance  
Who is responsible for this account?
Relationship to Patient:
Insurance Co.:
Group #:
Is patient covered by additional insurance? Yes No
Subscriber's Name:
Birthdate:
SS#:
Relationship to Patient:
Insurance Co.:
Group #:
Assignment and Release  
I certify that I, and/or my dependent(s), have insurance coverage with and assign directly to Dr. Boutwell all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.
 
The above-named dentist may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for servicesand determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.
   
________________________________________
Signature of Patient, Parent, Guardian or Personal Representative
 
Please print name of Patient, Parent, Guardian or Personal Representative
Date Monday 6th of February 2012 
Relationship to Patient
   
Phone Numbers  
Home:
Work:
Ext:
Cell Phone:
Spouse's Work:
Best time to reach you:
In Case of Emergency, Contact (Specify someone who does not live in your household.)
Name:
Relationship:
Home Phone:
Work Phone:
   
Dental History  
Reason for today's visit:
Former Dentist:
City/State:
Date of last dental visit:
Date of last dental X-rays:
Place a mark on "yes" or "no" to indicate if you have had any of the following:
Bad breath Yes No   Bleeding gums Yes No
Blisters on lips or mouth Yes No   Burning sensation on tongue Yes No
Chew on one side of mouth Yes No   Cigarette, pipe, or cigar smoking Yes No
Clicking or popping jaw Yes No   Dry mouth Yes No
Fingernail biting Yes No   Food collection between teeth Yes No
Foreign objects Yes No   Grinding teeth Yes No
Gums swollen or tender Yes No   Jaw pain or tiredness Yes No
Lip or cheek biting Yes No   Loose teeth or broken fillings Yes No
Mouth breathing Yes No   Mouth pain, brushing Yes No
Orthodontic treatment Yes No   Pain around ear Yes No
Periodontal treatment Yes No   Sensitivity to cold Yes No
Sensitivity to heat Yes No   Sensitivity to sweets Yes No
Sensitivity when biting Yes No   Sores or growths in your mouth Yes No
How often do you floss?        
How often do you brush?        
   
Health History  
Physician's Name:
Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Adipex, Fastin (brand names of phentermine).Pondimin (fenfluramine) and Redux (dexfenfluramine): Yes No
Place a mark on "yes" or "no" to indicate if you have had any of the following:
AIDS/HIV Yes No   Anemia Yes No
Arthritis, Rheumatism Yes No   Artificial Heart Valves Yes No
Artificial Joints Yes No   Asthma Yes No
Back Problems Yes No   Bleeding abnormall, with extractions or surgery Yes No
Blood disease Yes No   Cancer Yes No
Chemical Dependency Yes No   Chemotherapy Yes No
Circulatory Problems Yes No   Congenital Heart Lesions Yes No
Cortisone Treatments Yes No   Cough, persistant or bloody Yes No
Diabetes Yes No   Emphysema Yes No
Epilepsy Yes No   Fainting or dizziness Yes No
Glaucoma Yes No   Headaches Yes No
Heart Murmur Yes No   Heart Problems Yes No
Hepatitis Type _____ Yes No   Herpes Yes No
High Blood Pressure Yes No   Jaundice Yes No
Jaw Pain Yes No   Kidney Disease Yes No
Liver Disease Yes No   Low Blood Pressure Yes No
Mitral Valve Prolapse Yes No   Nervous Problems Yes No
Pacemaker Yes No   Psychiatric Care Yes No
Radiation Treatment Yes No   Respiratory Disease Yes No
Rheumatic Fever Yes No   Scarlet Fever Yes No
Shortness of Breath Yes No   Sinus Trouble Yes No
Skin Rash Yes No   Special Diet Yes No
Stroke Yes No   Swollen Feet or Ankles Yes No
Swollen Neck Glands Yes No   Thyroid Problems Yes No
Tonsillitis Yes No   Tuberculosis Yes No
Tumor or growth on head or neck Yes No   Ulcer Yes No
Venereal Disease Yes No   Weight Loss, unexplained Yes No
Do you wear contact lenses? Yes No        
Women:  
Are you pregnant? Yes No
Due Date
Are you nursing? Yes No
Taking birth control pills? Yes No
   
Medications  
List any medications you are currently taking and the correlating diagnosis:
Pharmacy Name:
Phone:
   
Allergies  
Aspirin Yes No Barbiturates (Sleeping pills) Yes No
Codeine Yes No Iodine Yes No
Latex Yes No Local Anesthetic Yes No
Penicillin Yes No Sulfa Yes No
Other Yes No