SDA Patient Registration Form
Email address *
Patient's Full Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Age *
Your answer
Gender
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Your Employer
Your answer
Your Occupation
Your answer
Social Security Number *
Your answer
Marital Status
Home Phone *
Your answer
Work Phone
Your answer
Are you a full time student?
If Married, Full Name of Spouse
Your answer
If Married, Spouse's Employer
Your answer
If Married, Spouse's Social Security Number
Your answer
If Patient is a Minor
Person Responsible for Account
Your answer
Person Responsible's Employer
Your answer
Person Responsible's Social Security Number
Your answer
Mother's Full Name
Your answer
Mother's Date of Birth
MM
/
DD
/
YYYY
Father's Full Name
Your answer
Father's Date of Birth
MM
/
DD
/
YYYY
Emergency Information
Name, address, and telephone number of a relative NOT living with you.
Relative's Name
Your answer
How are you related?
Your answer
Relative's Phone Number
Your answer
Relative's Street Address
Your answer
Relative's City
Your answer
Relative's State
Your answer
Dental Insurance Information
Policy Holder
Insured's Full Name
Your answer
Insured's Date of Birth
MM
/
DD
/
YYYY
Insured's Social Security Number
Your answer
Insured's Employer
Your answer
Insurance Company
Your answer
Insurance Company's Street Address
Your answer
Insurance Company's City
Your answer
Insurance Company's State
Your answer
Insurance Company's Phone Number
Your answer
Insurance Company's Zip Code
Your answer
Group Number
Your answer
Policy Number
Your answer
Dental History
Please check all that apply
If you have sensitivity, where?
Do you have or have had any of the following?
Previous Dentist Information
Name of Former Dentist
Your answer
Former Dentist's City
Your answer
Former Dentist's State
Your answer
Former Dentist's Phone
Your answer
Date of your last complete X-Rays
MM
/
DD
/
YYYY
Date of your last oral cancer screening
MM
/
DD
/
YYYY
Date of your last cleaning
MM
/
DD
/
YYYY
Why did you leave your former dentist?
Your answer
Affordable Teeth Whitening
If you could whiten your teeth for a cost anyone could afford, would you do it?
Do you currently or have you ever smoked or used chewing tobacco?
If yes, how much and for how long?
Your answer
If I could change my smile, I would:
On a scale of 1-10, with 10 being the highest, rate the following questions.
How important is your dental health to you?
Not important
Extremely important
Where would you rate your current dental health?
Not healthy
Extremely healthy
Today's Visit
What is the most important thing to you about your dental visit today?
Your answer
How did you hear about our office?
Your answer
What is the reason for your visit?
Your answer
Medical History
Please check any of the following that apply to you:
If other(s), please list below.
Your answer
Do you have an allergy to any of the following?
If any other allergies, please list.
Your answer
What medications are you currently taking?
Your answer
Are you under a physician's care?
If yes, for what?
Your answer
Who is your family physician/general practitioner?
Your answer
Family physician/general practitioner's phone number?
Your answer
WOMEN ONLY: Please check any that apply to you currently:
Sleep Screening Information
Do you snore loudly?
Do you often feel tired or fatigued after sleep?
Has anyone noticed that you quit breathing during sleep?
Do you take medication for high blood pressure?
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