New Patient Registration

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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 Information

How 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 Phone

Email*

Gender*

Marital Status

Single

Married

Divorced

Widowed

Seperated

Domestic Partner

Please check your preferred method of contact for appointment confirmation:

Home Phone

Cell Phone

Work Phone

Are you or the patient a minor?*

Yes

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 Information

Occupation

Employer

Years employed at current job

Emergency Information

Please list a contact to be reached in case of an emergency

Name

First Middle Last

Relation to patient

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Dental Insurance Information

Insurance

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 Insurance

Subscriber Name

DOB of policy account holder

MM slash DD slash YYYY

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

Medical History

It 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

Are you currently under a physician's care?

Yes

Physician's name

Physician's phone

Date 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 this

Have you ever used a BISPHOSPHONATE MEDICATION? (Often used to treat Osteoporosis)

Yes

Medications to treat Osteoporosis

Do you use tobacco in any form?

Yes

Please list type and frequency of use

Do you have any artificial joints or implants?

Yes

Please list which joints or implants and the date of surgery

Please 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

Are You nursing?

Yes

Are You pregnant?

Yes

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 describe

Please indicate if you have/had any of the following conditions

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 conditions

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 History

When 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

Have you had any periodontal (Gum) Treatments?

Yes

Do you now or have you had any pain/discomfort in your jaw joint?

Yes

Have you ever worn braces on your teeth (Orthodontics)?

Yes

Do your gums bleed, feel tender or irritated

Yes

Do you routinely experience dry mouth?

Yes

Do you like your smile?

Yes

Are you happy with the color of your teeth?

Yes

Do you regularly use dental floss?

Yes

Do you wear dentures?

Yes

Are you unhappy with your dentures?

Yes

Do you gag easily?

Yes

Are your teeth sensitive to heat, cold or anything else?

Yes

Are you apprehensive about dental treatment?

Yes

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?

Agreement

Purpose 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
office@atriumdentalcenter.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

Comments

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