Dental Clinic Registration Form
Dental Clinic Registration Form
Please fill out the form below with accurate and up-to-date information.
Personal Information
Name:
Date of Birth:
Gender:
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Male
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Female
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Marital Status:
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Single
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Married
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Phone number:
Email:
Address:
Emergency Contact
Name:
Phone number:
Relationship:
General Health Information
Do you have any known allergies?
If yes, please specify:
Are you currently taking any medications?
If yes, please specify:
Do you have any chronic conditions (e.g., diabetes, high blood pressure)?
If yes, please specify:
Have you had any major surgeries in the past?
If yes, please specify:
Dental History
Date of your last dental visit:
Reason for your last dental visit:
Have you ever had any of the following dental procedures?
Check all that apply
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Fillings
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Root Canal Treatment
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Braces/Orthodontic Treatment
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Tooth Extraction
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Gum Surgery
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Dental Implants
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Are you currently experiencing any dental pain or discomfort?
If yes, please describe:
Do you have any dental prosthetics (e.g., crowns, bridges, dentures)?
If yes, please describe:
Do you grind or clench your teeth?
Do your gums bleed when you brush or floss?
Consent and Agreement
By signing this form, I confirm that the information provided is accurate to the best of my knowledge. I consent to the necessary dental treatments and authorize the clinic to bill my insurance provider for services rendered (if applicable).
Date:
Thank you for completing the registration form.
We look forward to serving your dental care needs!
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