New Patient Registration Form Thank you for visiting our office.  We want your visit to be pleasant and comfortable. Please help us by completing this form. All of this information is completely confidential. Patient Information Full Name (Last, First, Initial): ,    Preferred Name: Address: City State, Zip: ,     Phones: Home-    Work-    Cell- E-mail Address: Soc Sec #: Sex: Male Female Date of Birth: Marital Status: Single Married Widowed Separated Divorced Patient Employer/Occupation: Emergency Contact: Spouse's Name: Spouse's Employer/Occupation: How did you hear about our office? Responsible Party Information Person Financially Responsible: Relation to patient:     Address: City State, Zip: ,     Phones: Home-    Work- Employer: Soc Sec #: Date of Birth: Dental Insurance Information Is patient covered by dental insurance? Yes No (If yes, please complete the following:)   Policy Holder Name: Relation to Patient: Address: City State, Zip: , Phones: Home-    Work- Soc Sec #: Date of Birth: Insurance Company Name: Insurance Company Phone: Group #: Subscriber ID#:     Is patient covered by additional dental insurance? Yes No (If yes, please complete the following:)       Policy Holder Name: Relation to Patient: Address: City State, Zip: , Phones: Home-    Work- Employer: Soc Sec #: Date of Birth: Insurance Company Name: Insurance Company Phone: Group #: Subscriber ID#: INSURANCE AUTHORIZATION & FINANCIAL RESPONSIBILITY AGREEMENT   I understand that I am financially responsible for all charges whether or not paid by insurance. I assign all insurance benefits directly to the doctor otherwise payable to me for services rendered. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions. Signature (Parent/Guardian if under age 18) Relationship (if patient is under age 18) Date   Medical History Patient Name: Physician's Name: Phone: Date of Last Visit: Please check the box if you have ever had any of the following: AIDS or HIV positive Acid Reflux/ G.E.R.D Arthritis, (Supply Type in Details Below) Artificial joints Asthma Breast Augmentation Cancer Chemical Dependency Diabetes, (Supply Type in Details Below) Eating disorder Epilepsy Excessive bleeding Glaucoma Hepatitis, (Supply Type in Details Below) Kidney problems Liver problems or Jaundice Lung or breathing problems Rheumatic Fever Sinus trouble Smoking/chewing tobacco Stroke Swollen neck glands Thyroid problems Tuberculosis Heart Problems: Allergies: Women: Artificial valves Congential heart defects Heart Murmur Heart Surgeries High blood pressure Infective (Bacterial) Endocarditis Low blood pressure Mitral Valve Prolapse Pacemaker Other (Supply details below) Antibiotics for dental treatment Currently under a physician's care Serious illnesses/hospitalizations Aspirin Codeine Latex Local anesthetic Penicillin Sulfa Other Allergies:  Are you pregnant?  No Yes Due when?  Are you nursing?  No Yes Medications: Please list medications you are currently taking and why Dental History (New Patients Only) Checkmark if you have ever had any of the following: Bad breath problem Biteguard / Nightguard Canker sores in mouth Cold sores on outer lips Dental anesthetic problems Excessive gag reflex Fear of dental care Frequent headaches, neck aches Full dentures / Partial dentures Oral surgery Orthodontics (braces) TMJ, jaw joint pain or treatment Gum disease treatment Checkmark if you currently have any of the following: Bleeding gums Broken tooth or filling Clenching or grinding of teeth Clicking or popping jaw Dry mouth Food packing between teeth Loose tooth Mouth breathing Pain Sensitivity to - heat - cold - biting Sensitivity to - sweets - pressure Sores or growths in mouth Swelling Tired, sore or painful jaw joint Toothache Vague ache Pain around ear Other: Give details and location of the above checked items:     How often do you brush? How often do you floss? What type toothbrush do you use? Ultrsoft Soft Medium Hard Electric     Reason for today's visit Former Dentist , City/State:    Phone: Date and reason of last dental visit: Date of last dental X-rays:     What have you liked about any dental office you've been to? What have you liked LEAST about any dental office you've been to? TREATMENT AUTHORIZATION I have reviewed the information on this form and it is accurate to the best of my knowledge. I authorize and give consent for the dentist and/or team of this office to perform dental services as agreed between doctor and patient and/or guardian, including the use of local anesthetic and other medication as indicated. Signature (Parent/Guardian if under age 18) Relationship (if patient is under age 18) Date ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES. Dental/personal information will only be released to your dental insurance company on record or other physicians involved in your treatment. We will be unable to discuss any treatment or release any of your dental information to anyone else without your written consent. Dr Brooks and staff may release information to the following: Name Relationship Name Relationship Name Relationship Do not release any information to anyone except insurance company or other treating doctors. I have received a copy of this office's Notice of Privacy Practices and realize this release of information consent will remain in effect until terminated by me in writing.     Patient Signature Date Please enter code above in the field below.