Patient Registration

Welcome, and thank you for choosing us for your prosthetic treatment. We will strive to do our best to provide you with the finest care. If you have any questions about our office or this form, please do not hesitate to contact us.

PERSONAL INFORMATION

Miss Mrs. Ms. Mr. Dr.

Female Male

HEALTH HISTORY

 

Do you have, or have you had, any of the following diseases or problems?

Rheumatic fever, rheumatic heart disease

Kidney trouble


Heart trouble, heart attack, high blood pressure, stroke

Diabetes


Radiation or treatment for a tumour or other growth

Psychiatric disorders


Blood disorders, anemia

Special needs


Abnormal bleeding, prolonged healing

Asthma, hayfever


Fainting spells, seizures

Low blood pressure


Migraines or tension headaches

Artificial joints


Hepatitis, jaundice, liver disease

Are you currently pregnant?


AIDS, HIV, autoimmune deficiencies

Osteoporosis


Sleep Apnea


ORAL HEALTH

  1. Do you have pain around your ears, eyes or other parts of your face?
  2. Do you clench or grind your teeth while awake or asleep?
  3. Are you aware of any sores or lumps in your mouth at present?
  4. Do you ever hear grating or popping sounds from your jaw joint?

IMPLANTS

PATIENTS WITH FULL OR PARTIAL DENTURES

  1. Please indicate the type(s) of denture you wear:

    Upper
    Lower

    Upper
    Lower

  2. When were your dentures made?

Relaxed
Mildly Apprehensive
Very Nervous But Under Control
Extremely Apprehensive

Please be advised that your records may be shared with another dental office if a registration is required for your dental treatment, and only required information will be forwarded to your insurance company.

Should you need to reschedule or cancel your appointment, we require 2 working days notice to avoid a late fee.

Payment is expected at the time the services are rendered or initiated. Our office does not take assignment on insurance plans, but we are happy to fill out your documents so that you are able to submit for any coverage that your plan may provide. We accept cash, Visa, MasterCard and Debit.

* 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 (or the patient's) health. It is my responsibility to inform the dental office of any changes in medical status; if ever I have any change in my health condition or the medications I take, I will inform the Doctor on my next appointment without fail. I also understand that I am fully responsible for the financial aspect of my dental treatment to Anh Nguyen Dentistry Professional Corporation.