Patient Registration & Medical History

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Please fill out this form prior to your visit. All information is kept confidential and secure.

Email *

1. Patient Information

First Name *

Last Name *

Date of Birth *

YYYY

Phone Number *

Mailing Address *

2. Dental Insurance

Primary Dental Insurance Carrier (if any)

e.g. Delta Dental, MetLife, None...

Note: We accept all major dental PPO insurance plans. For Medi-Cal and Medicare Advantage users, our front desk will contact you shortly with details.

3. Medical History & Lifestyle

Do you consider yourself to be in good health? *

Yes

Fair

Approx. date of last dental visit?

Format: MM/YYYY

Are you currently taking any medications?

Please list names or write "None"

Allergies (Check all that apply)

Penicillin

Latex

Codeine

Sulfa Drugs

Other:

Conditions (Check all that apply)

High Blood Pressure

Diabetes

Heart Disease

Asthma

Artificial Joints

Cancer

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