New Patient Registration "*" indicates required fields Step 1 of 6 16% This is a secure web form. We do not share or provide access to your information. Atrium Dental Center takes your privacy very seriously.Patient InformationHow did you learn about Atrium Dental Center?* Date MM slash DD slash YYYY Name* First Middle Last SSN Preferred Name* Birth Date* MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home Phone Number*Cell Phone*Work PhoneEmail* Gender*MaleFemaleUnspecifiedMarital Status Single Married Divorced Widowed Seperated Domestic Partner Please check your preferred method of contact for appointment confirmation: Home Phone Cell Phone Work Phone Email Are you or the patient a minor?* Yes No Parent or Guardian Name First Middle Last Parent or Guardian Email Relation To Patient Parent or Guardian Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Employer InformationOccupation Employer* Years employed at current job Emergency InformationPlease list a contact to be reached in case of an emergencyName First Middle Last Relation to patient PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Dental Insurance InformationInsurance I do not have dental insurance Subscriber Name* DOB of policy account holder* MM slash DD slash YYYY Subscriber Employer* Subscriber SSN/ID* Group Number* Insurance Company Name* Insurance Phone*Insurance Company Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Secondary InsuranceSubscriber Name DOB of policy account holder MM slash DD slash YYYY Subscriber SSN/ID Group Number Insurance Company Name Insurance PhoneInsurance Company Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Medical HistoryIt is important that we know about your medical and dental history. These facts have a direct bearing on your dental health. This information is strictly confidential and will not be released to anyone.Do you have any current health problems? Yes No Are you currently under a physician's care?* Yes No Physician's name Physician's phoneDate of last visit? MM slash DD slash YYYY For what are you receiving physician care?What medications are you currently taking?Please list all, including dosage (if known) & prescribing physician. If your list is extensive then bring a copy for us and we'll happily help you with thisHave you ever used a BISPHOSPHONATE MEDICATION? (Often used to treat Osteoporosis) Yes No Medications to treat OsteoporosisDo you use tobacco in any form? Yes No Please list type and frequency of useDo you have any artificial joints or implants? Yes No Please list which joints or implants and the date of surgeryPlease check which of the following you have had, or presently have Angina Pectoris Arthritis (Rheumatism) Artificial Heart Valve Asthma Back Problems Blood Cancer Chemotherapy Congenital Heart Defect Diabetes Difficulty Breathing Drug Abuse Emphysema Facial Surgery Fainting Spells Fever Blisters (Cold Sores) Headaches Heart Attack Heart Murmur Heart Problems Heart Surgery Hemophilia Hepatitis A Hepatitis B Hepatitis C High Blood Pressure HIV + AIDS Jaw Pain Kidney Problems Liver Disease Nervous Problems Pace Maker Radiation Therapy Respiratory Disease Seizures Sexually Transmitted Disease Shingles Shortness of Breath Sinus Problems Stroke Please add any details you feel would be beneficial below.Are You taking birth control pills? Yes No Are You nursing? Yes No Are You pregnant? Yes No If pregnant, how many weeks along are you? Are you allergic or have you reacted adversely to any of the following medications? Aspirin Erythromycin Nitrous Oxide Penicillin Local Anesthetic Latex Codeine Other PHARMACY Hydrocodone Cephalexin None Are you aware of being allergic to any other medications or substances? If yes, please list.Do you have any disease, condition or problem that you feel we should know about? If so, please describePlease indicate if you have/had any of the following illnesses Asthma Cancer Chemo High BloodPressure Low Blood Pressure Diabetes Drug Abuse Emphysema Seizures Fainting Heart Attack Heart Murmur Hemophilia Cold Sores Hepatits B Hepatits C Please indicate if you have/had any of the following illnesses Pregnant/Nursing Kidney Disease Sinus Problems Stroke Jaw Pain Sleep Apnea Clenching or grinding habits Bleeding Gums HIV Pacemaker Liver Disease Radiation Therapy Artificial Joints or implants/valves Bisophosphonate Medication Tobacco Use Arthritis Dental HistoryWhen was your last dental visit?* MM slash DD slash YYYY when was the last time you had a professional cleaning?* MM slash DD slash YYYY Last complete dental exam? MM slash DD slash YYYY Last complete X-Rays? MM slash DD slash YYYY Your current dental health is Good Fair Poor Who was your previous dentist? What immediate concern do you have that we can help you with?Please answer the following:Do you require antibiotics before dental treatment? Yes No Have you had any periodontal (Gum) Treatments? Yes No Do you now or have you had any pain/discomfort in your jaw joint? Yes No Have you ever worn braces on your teeth (Orthodontics)? Yes No Do your gums bleed, feel tender or irritated Yes No Do you routinely experience dry mouth? Yes No Do you like your smile? Yes No Are you happy with the color of your teeth? Yes No Do you regularly use dental floss? Yes No Do you wear dentures? Yes No Are you unhappy with your dentures? Yes No Do you gag easily? Yes No Are your teeth sensitive to heat, cold or anything else? Yes No Are you apprehensive about dental treatment? Yes No How many times do you brush each day? How many times do you floss each week? Be honest, we won't judge!Is there any specific service and/or concern you would like to inquire about? AgreementPurpose of Consent: By signing this form, you consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations. Notice of Privacy Practices: You have the right to read the Notice of Privacy Practices before you decide whether to sign this consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain. You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by visiting this link or contacting: Atrium Dental Center Attn: Office Manager email@example.com 1545 J Street Bedford, IN 47421 Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation. Terms and Conditions* I Agree NameThis field is for validation purposes and should be left unchanged.