Registration

Please fill out this form if you are visiting us for the first time. All information is treated as confidential.



    Are you taking any prescription or non-prescription medication, pills, or inhalers?
    If yes, please list:

    Have you ever had any allergies to medications or other substances (e.g.Latex)
    If yes, please list :

    Have you ever had any of the following:
    Heart Murmur
    Open heart surgery
    High or low blood pressure
    Rheumatic fever
    Other heart trouble/stroke
    Asthma
    Chest/lung/breathing problems
    Eczema
    Epilepsy
    Radiotherapy or Chemotherapy
    HIV/Hepatitis B or C
    Diabetes
    Tuberculosis
    Bruising or blood disorder
    Other infectious diseases
    Depression/anxiety or stress
    Smoker
    Any artificial joints
    Any Bisphosphonate medications, including Fosamax
    Any excessive bleeding from previous surgery or dental treatment
    Any reaction to anesthetic
    Women: Are you pregnant or breastfeeding?
    Any other health matters that you think you should let the dentist know:

    Name of patient/parent/guardian Date