Patient Sign-in

Patient Registration Form

Patient Sign-in
New patient Registration
Medical History
Medical history
Dental History
Dental history

Patient Registration( * mandatory to fill )

Please Select Type Of Registration
Adult
Child

Personal Information( * mandatory to fill )

Responsible Party( * mandatory to fill )

Telephone

       Home Work Car

Please select below

Primary Insurance Policy Holder?
Yes No
Secondary Insurance Policy Holder?
Yes No
I have read the above choices

Dental Insurance Information

Additional Insurance

Dental History

Have you ever used or are currently using topical fluoride ?
Yes
No
Do you have any dental problems now ?
Yes
No

Dental History

Hot or Cold ?
Yes
No
Sweets ?
Yes
No
Biting or Chewing ?
Yes
No
Have you noticed any mouth odors or bad tastes ?
Yes
No
Do you frequently get cold sores, blisters or any other oral lesions ?
Yes
No
Do your gums bleed or hurt ?
Yes
No
Have your parents experienced gum disease or tooth loss?
Yes
No
Have you noticed any loose teeth or change in your bite ?
Yes
No
Does food tend to become caught in between your teeth ?
Yes
No
Clench or grind your teeth while awake or sleep ?
Yes
No
Bite your lips or Cheeks regularly?
Yes
No
Hold foreign objects with your teeth (pencils, pipes ,pins, nails, fingernail)?
Yes
No
Mouth breath while awake or sleep ?
Yes
No
Have tired jaws,especially in the morning ?
Yes
No
Snore or have any other sleeping disorders ?
Yes
No
Smoke or chew tobacco or use other tobacco products ?
Yes
No
Orthodontic Treatment ?
Yes
No
Oral Surgery ?
Yes
No
Periodontal Treatment ?
Yes
No
Your teeth ground or bite adjusted ?
Yes
No
A bite plate or mouth guard ?
Yes
No
A Serious injury to the mouth or head ?
Yes
No
Cliking or Popping of the jaw?
Yes
No
Pain(joint, ear,side of face)?
Yes
No
Difficulty in opening or closing mouth?
Yes
No
Difficulty in chewing on either side of the mouth?
Yes
No
Headache, Neckache or Shoulder ache?
Yes
No
Sore Muscles(neck,shoulder)?
Yes
No
Are you satisfied with your teeth appearance?
Yes
No
Would you like to keep all of your teeth all if your life?
Yes
No
Do you feel nervous about having dental treatment?
Yes
No
Have you ever had an upsetting dental experience ?
Yes
No
Have you ever been told to take a pre-medication prior to dental treatment?
Yes
No
Is there anything else about having dental treatment that you would like us to know ?
Yes
No
Have you had any medical care within the past two years ?
Yes
No
Have you taken any medication or drugs during the past two years ?
Yes
No
Are you currently taking any medication, drugs, pills or herbal remedies, including regular dosages of aspirin?
Yes
No
Have you ever taken prescription medications for weight loss (diet pills)?
Yes
No
If yes to any of the above, did you have a medical exam for heart issues ?
Yes
No
Have you ever taken bone loss prevention drugs such as Fosamax. Actonel, Boniva or other similar drugs ?
Yes
No
Are you aware of having an allergic (or adverse) reaction to any substance or medication?
Yes
No
Have you been a patient in the hospital during the past five years ?
Yes
No
Heart(Surgery, Disease, Attack)
Yes
No
Chest Pain
Yes
No
Congenital Heart Disease
Yes
No
Heart Murmur
Yes
No
High/Low Blood Pressure
Yes
No
Mitral Valve Prolapse
Yes
No
Artificial Heart Valve/Pacemaker
Yes
No
Rheumatic Fever
Yes
No
Arthritis/Rheumatism
Yes
No
Cortisone Medicine
Yes
No
Swollen Ankles
Yes
No
Stroke
Yes
No
Diet (Special/Restricted)
Yes
No
Artificial Joints (hip, knee, etc.)
Yes
No
Kidney Trouble
Yes
No
Ulcers
Yes
No
Diabetes
Yes
No
Thyroid Problems
Yes
No
Glaucoma
Yes
No
Contact lenses
Yes
No
Emphysema
Yes
No
Chronic Cough
Yes
No
Tuberculosis
Yes
No
Asthma
Yes
No
Hay Fever/Allergy/Hives
Yes
No
Latex Sensitivity
Yes
No
Sinus Trouble
Yes
No
Radiation Therapy
Yes
No
Chemotherapy
Yes
No
Tumors
Yes
No
Hepatitis A/B/C
Yes
No
Venereal Disease
Yes
No
A.I.D.S./H.I.V. Positive
Yes
No
Cold Sores/Fever Blisters
Yes
No
Blood Transfusion
Yes
No
Hemophilia
Yes
No
Sickle Cell Disease
Yes
No
Bruise Easily
Yes
No
Liver Disease/Yellow Jaundice
Yes
No
Neurological Disorders
Yes
No
Epilepsy or Seizures
Yes
No
Fainting or Dizzy Spells
Yes
No
Nervous/Anxious
Yes
No
Psychiatric/Psychological Care
Yes
No
Have you lost or gained more than 10 pounds in the past year?
Yes
No
Do you have or have you had any disease, condition, or problem not listed?
Yes
No
Are you a woman?
Yes
No

I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed. you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of any change in my health or medication.

SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

Authorization And Release

I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such Dental care to third party payors and/or other 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 dependents.

SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

Financial Agreement

For your convenience, we offer the following methods of payment. Please check the option which you prefer. Payment in full at each appointment.

Cash
Personal Check
 
Credit Card
 

Late Charges

If I do not pay the entire new balance within 25 days of the monthly billing date, a late charge of 1.5% on.the balance then unpaid and owed will be assessed each month (if allowed by law). I realize that failure to keep this account current may result in you being unable to provide additional dental services except for dental emergencies or where there is prepayment for additional services. In the case of default on payment of this account. I agree to pay collection costs and reasonable attorney fees incurred in attempting to collect on this amount or any future outstanding account balances.

Thank you for filling out this form completely. The information you have provided will help us serve your dental healthcare needs more effectively and efficiently. If you have any questions at anytime, please ask - we are always happy to help.

(Please click below to draw/upload sign)
(Your IP Address : )

Your Child

Welcome to our practice! We strive to make each of your child's visits pleasant and comfortable.Our goal is to teach your child oral habits which will help keep their smile beautiful for their lifetime


Mother

Guardian
Stepmother

Father

Guardian
Stepfather

Responsible Party


Primary Dental Insurance

Orthodontic Treatment
Yes
No

Additional Dental Insurance

Orthodontic Coverage
Yes
No

Health History

Your child's overall health as well as any medications which your child takes could have an important interrelationship with the dental care your child receives. Please answer each of the following questions completely.

Asthma
Yes
No
Cancer
Yes
No
Hepatitis
Yes
No
HIV/AIDS
Yes
No
Heamophilia
Yes
No
Diabetes
Yes
No
Allergies
Yes
No
Rheumatic Fever
Yes
No
Cogenital Heart Defect
Yes
No
Handicaps/Disabilities
Yes
No
Convulsions/Epilepsy
Yes
No
Tuberculosis
Yes
No
Abnormal bleeding
Yes
No
Heart Murmer
Yes
No

Child's Habits

Does your child take flouride supplements ?
Yes
No

Does Your Child

Suck thumb/Finger?
Yes
No
Suck/Bite Lips?
Yes
No
Bite/Chew Nails?
Yes
No
Chew Hard objects?
Yes
No
Grind Teeth?
Yes
No
Clench Jaws?
Yes
No
Is your child's water flouridated ?
Yes
No

Authorization and Release

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my child's health. It is my responsibility to inform the dental office of any changes in my child's medical status. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to my child during the period of such Dental care to third party payors and/or other 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 dependents.

Health History Update

(Please click below to draw/upload sign)
(Your IP Address : )
Patient Sign-in
Thank you for visiting Unique south Dental. We want your visit to be pleasant and comfortable.Please help us by completing this form

Personal Information

Date Of Birth       Social Security Number       First Name       Last Name       Middle Initial       Wishes to be Called       Gender       Marital Status       Address       City       State       Zip Code       Email       Employer       Occupation       Referred By      

Responsible Party

Name       Relationship To Patient       Date Of Birth       Driver's License       Social Security Number       Email       Address       City       State       Zip Code       Employer       Occupation       Home Phone       Cell Phone       Work Phone       Ext      

Telephone

Home Phone       Cell Phone       Work Phone       Ext      
Home Work Car Time       Days       Name       Relationship       Work Phone       Home Phone      

Dental History

What is the reason for today's visit ?       Date of last Dental visit?       Last Dental Cleaning?       Last Full Mouth X-rays?       What was done at your last dental visit ?       Previous Dentist Name       Address       City       State       Zip Code       Telephone       How often do you have dental examinations ?       How often do you brush your teeth ?       How often do you floss ?      
Have you ever used or are currently using topical fluoride?
Yes No
What other dental aids do you use ?(Interplak, Toothpick etc)      
Do you have any dental problems now ?
Yes No
If yes, Please Specify?      

Dental History

Hot or Cold ?
Yes No
Sweets ?
Yes No
Biting or Chewing ?
Yes No
Have you noticed any mouth odors or bad tastes ?
Yes No
Do you frequently get cold sores, blisters or any other oral lesions ?
Yes No
Do your gums bleed or hurt ?
Yes No
Have your parents experienced gum disease or tooth loss?
Yes No
Have you noticed any loose teeth or change in your bite ?
Yes No
Does food tend to become caught in between your teeth ?
Yes No
If yes, Please Specify?      
Do You
Clench or grind your teeth while awake or sleep ?
Yes No
Bite your lips or Cheeks regularly?
Yes No
Hold foreign objects with your teeth (pencils, pipes, pins, nails, fingernail)?
Yes No
Mouth breath while awake or sleep ?
Yes No
Have tired jaws,especially in the morning ?
Yes No
Snore or have any other sleeping disorders ?
Yes No
Smoke or chew tobacco or use other tobacco products ?
Yes No
Have You Ever Had
Orthodontic Treatment ?
Yes No
Oral Surgery ?
Yes No
Periodontal Treatment ?
Yes No
Your teeth ground or bite adjusted ?
Yes No
A bite plate or mouth guard ?
Yes No
A Serious injury to the mouth or head ?
Yes No
Have You Experienced
Cliking or Popping of the jaw?
Yes No
Pain(joint, ear,side of face)?
Yes No
Difficulty in opening or closing mouth?
Yes No
Difficulty in chewing on either side of the mouth?
Yes No
Headache, Neckache or Shoulder ache?
Yes No
Sore Muscles(neck,shoulder)?
Yes No
Are you satisfied with your teeth appearance?
Yes No
Would you like to keep all of your teeth all if your life?
Yes No
Do you feel nervous about having dental treatment?
Yes No
Have you ever had an upsetting dental experience ?
Yes No
If yes, Please Specify?      
Have you ever been told to take a pre-medication prior to dental treatment?
Yes No
Is there anything else about having dental treatment that you would like us to know ?
Yes No
If yes, Please Specify?      

Medical History

Physician's Name       Phone      
Have you had any medical care within the past two years ?
Yes No
If yes, Please describe ?      
Have you taken any medication or drugs during the past two years ?
Yes No
Are you currently taking any medication, drugs, pills or herbal remedies, including regular dosages of aspirin?
Yes No
If yes, please list name and dosage ?      
Have you ever taken prescription medications for weight loss (diet pills)?
Yes No
If yes, did you take any of the following?(Fen-Phen,Pondimen or Redux)      
If yes to any of the above, did you have a medical exam for heart issues ?
Yes No
Have you ever taken bone loss prevention drugs such as Fosamax. Actonel, Boniva or other similar drugs ?
Yes No
Are you aware of having an allergic (or adverse) reaction to any substance or medication?
Yes No
If yes, please specify?      
Have you been a patient in the hospital during the past five years?
Yes No
Heart(Surgery, Disease, Attack) Yes No Chest Pain Yes No
Congenital Heart Disease Yes No Heart Murmer Yes No
High/Low Blood Pressure Yes No Mitral Valve Prolapse Yes No
Artificial Heart Valve/Pacemaker Yes No Rheumatic Fever Yes No
Arthritis/Rheumatism Yes No Cortisone Medicine Yes No
Swollen Ankles Yes No Stroke Yes No
Diet (Special/Restricted) Yes No Artificial Joints (hip, knee, etc.) Yes No
Kidney Trouble Yes No Ulcers Yes No
Diabetes Yes No Thyroid Problems Yes No
Glaucoma Yes No Contact lenses Yes No
Emphysema Yes No Chronic Cough Yes No
Tuberculosis Yes No Asthma Yes No
Hay Fever/Allergy/Hives Yes No Latex Sensitivity Yes No
Sinus Trouble Yes No Radiation Therapy Yes No
Chemotherapy Yes No Tumors Yes No
Hepatitis A/B/C Yes No Venereal Disease Yes No
A.I.D.S./H.I.V. Positive Yes No Cold Sores/Fever Blisters Yes No
Blood Transfusion Yes No Hemophilia Yes No
Sickle Cell Disease Yes No Bruise Easily Yes No
Liver Disease/Yellow Jaundice Yes No Neurological Disorders Yes No
Epilepsy or Seizures Yes No Fainting or Dizzy Spells Yes No
Nervous/Anxious Yes No Psychiatric/Psychological Care Yes No
Have you lost or gained more than 10 pounds in the past year?
Yes No
Do you have or have you had any disease, condition, or problem not listed?
Yes No
If yes,please list?
Are you a woman?
Yes No

Pregnant/trying to get pregnant Nursing Taking birth control pills? None

I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed. you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of any change in my health or medication.

History Review      
 
Jun 26, 2018
( IP:103.72.179.228 )
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

Authorization And Release

I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such Dental care to third party payors and/or other 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 dependents.

  
Jun 26, 2018
( IP:103.72.179.228 )
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

FINANCIAL AGREEMENT

For your convenience, we offer the following methods of payment. Please check the option which you prefer. Payment in full at each appointment.


Cash Personal Check Credit Card
I wish to discuss the dental office's policyI wish to discuss the dental office's policy

Late Charges

If I do not pay the entire new balance within 25 days of the monthly billing date, a late charge of 1.5% on.the balance then unpaid and owed will be assessed each month (if allowed by law). I realize that failure to keep this account current may result in you being unable to provide additional dental services except for dental emergencies or where there is prepayment for additional services. In the case of default on payment of this account. I agree to pay collection costs and reasonable attorney fees incurred in attempting to collect on this amount or any future outstanding account balances.

Thank you for filling out this form completely. The information you have provided will help us serve your dental healthcare needs more effectively and efficiently. If you have any questions at anytime, please ask - we are always happy to help

  
Jun 26, 2018
( IP:103.72.179.228 )
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS
Patient Sign-in
Thank you for visiting Unique south Dental. We want your visit to be pleasant and comfortable.Please help us by completing this form

Your Child

Patient ID#       Child's Name       Nick Name       Gender       Date Of Birth       Age       SSN/SIN#       School       Grade       Address       City       State       Zip Code       Phone      

Guardian Stepmother

Mother

Name       Home Phone       Cell Phone       Work Phone       Social Security Number       Employer       Occupation       Driving License Number      

Guardian Stepfather

Father

Name       Home Phone       Cell Phone       Work Phone       Social Security Number       Employer       Occupation       Driving License Number      

Responsible Party

Name       Relationship       Address       City       State       Zip Code       Social Security Number       Driving License Number       Email      

Primary Dental Insurance

Insured's Name       Relationship       Date Of Birth       Social Security Number       Employer       Date Of Employed       Occupation       Insurance Company       Group#       Emp.#       Address       City       State       Zip Code       Deductible       Amount already used       Maximum Annual Benefit      
Orthodontic Treatment
Yes No

Additional Insurance

Insured's Name       Relationship       Date Of Birth       Social Security Number       Employer       Date Of Employed       Occupation       Insurance Company       Group#       Emp.#       Address       City       State       Zip Code       Deductible       Amount already used       Maximum Annual Benefit      
Orthodontic Coverage
Yes No

Parent's Marital Status      

Who is Responsible for making Appointments

Name       Home Phone       Cell Phone       Work Phone       Ext       Time       Days      

Health History

Has your child had difficulty with previous visits ?       Does your child have a persistent cough or throat clearing not associated with a known illness (lasting more than 3 weeks)?       Has your child ever taken Fen-Phen/Redux?      
Asthma
Yes No
Cancer
Yes No
Hepatitis
Yes No
HIV/AIDS
Yes No
Heamophilia
Yes No
Diabetes
Yes No
Allergies
Yes No
Rheumatic Fever
Yes No
Cogenital Heart Defect
Yes No
Handicaps/Disabilities
Yes No
Convulsions/Epilepsy
Yes No
Tuberculosis
Yes No
Abnormal bleeding
Yes No
Heart Murmer
Yes No

Child's Habits

How often does your child brush?       How often does your child floss?       Last Dental Visit       Previous Dentist       Child's Physician       Phone Number       Child's Date Of Birth      
Does your child take flouride supplements ?
Yes No

Does Your Child

Suck thumb/Finger?
Yes No
Suck/Bite Lips?
Yes No
Bite/Chew Nails?
Yes No
Chew Hard objects?
Yes No
Grind Teeth?
Yes No
Clench Jaws?
Yes No
Is your child's water flouridated ?
Yes No

Authorization And Release

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my child's health. It is my responsibility to inform the dental office of any changes in my child's medical status. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to my child during the period of such Dental care to third party payors and/or other 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 dependents.

Dentist Review

Comments       Date      
 
SIGNATURE DATE & IP ADDRESS

Health History Updates

Date       Comments      
 
SIGNATURE DATE & IP ADDRESS

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