Register | Morris Dental

New Patient Registration Form

Welcome! Our team of experienced dental professionals is committed to providing you with personalized care that prioritizes your smile and oral health.

REGISTRATION FORM

New Patient Form

Patient Information

Name(Required)

First Last

DOB:(Required)

MM slash DD slash YYYY

SSN#: *(Required)

Marital Status : *(Required)

Minor

Married

Divorced

Separated

Widowed

Address

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

Occupation:

Employer:

Phone:

Alternate Phone #:

Email(Required)

Preferred Method of Communication:

Phone Call

Text Cell

Emergency Contact Name:

Relationship to Patient:

Phone #:

Who may we thank for referring you?

Fill the above section.

Please be prepared to give your insurance card to the receptionist.

Primary Insurance

Name of Insured:

DOB:

MM slash DD slash YYYY

SSN#:

Relationship to Patient:

Is this person a patient here?

Occupation:

Employer:

Employer Address:

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

Primary Insurance Co.:

Group #:

Policy/ID #:

Patient Medical History

Physician:

Office Phone

Date of Last Exam:

MM slash DD slash YYYY

Please select the appropriate answer.

Are you under medical treatment now?

Yes

Have you been hospitalized for any surgical operation or serious illness within the last 5 years?

Yes

If yes please explain:

Are you taking any medication(s) including non-prescription medicine?

Yes

Do you use tobacco?

Yes

Do you use controlled substances?

Yes

Do you wear contact lenses?

Yes

Do you have a persistent cough or throat clearing not associated with a known illness (lasting more than 3 weeks)?

Yes

Women Only:

Are you pregnant or think you may be pregnant?

Yes

Are you nursing?

Yes

Are you taking oral contraceptives?

Yes

Are you allergic to or have you had any reactions to the following?

Local Anesthetics (e.g. Novocain)

Sulfa Drugs

Sedatives

Iodine

Latex Rubber

Penicillin or any other Antibiotics

Barbiturates

Any Metals (e.g. Nickel)

Aspirin

Codeine

If yes, please specify:

Please list any other allergies:

Do you have or have you had any of the following?

High Blood Pressure

Heart Attack

Rheumatic Fever

Swollen Ankles

Fainting/Seizures

Asthma

Low Blood Pressure

Epilepsy/Conculsions

Leukemia

Diabetes

Kidney Diseases

AIDS or HIV Infection

Thyroid Problem

Heart Disease

Cardiac Pacemaker

Heart Murmur

Angina

Mitral Valve Prolapse

Other Heart Condition

Frequently Tired

Anemia

Emphysema

Cancer

Arthritis

Joint Replacement or Implant

Hepatitis/Jaundice

Sexually Transmitted Disease

Stomach Troubles/Ulcers

Chest Pains

Easily Winded

Stroke

Hay Fever/Allergies

Tubeerculosis

Radiatioon Therrapy

Glaucoma

Recent Weight Loss

Liver Disease

Respiratory Problems

Dizziness/Nausea

Patient Dental History

Previous Dentist and Location:

Date of Last Exam:

MM slash DD slash YYYY

Please select the appropriate answer:

Do your gums bleed while brushing or flossing?

Yes

Are your teeth Sensitive to sweet or sour liquids/foods?

Yes

Do you feel pain in any of your teeth?

Yes

Do you have any sores or lumps in or near your mouth?

Yes

Have you had any head, neck, or jaw injuries?

Yes

Do you have frequent headaches?

Yes

Do you clench or grind your teeth?

Yes

Do you bite your lips or cheeks frequently?

Yes

Have you ever had any difficult extractions in the past?

Yes

Have you ever had any prolonged bleeding following extractions?

Yes

Have you had any orthodontic treatment?

Yes

Do you wear dentures or partials?

Yes

Do you wear dentures or partials?

Yes

Have you ever experience any of the following problems in your jaw?

Leave blank if you've never experienced any of the problems.

Clicking

Pain (Joint, ear, side of face)

Difficulty in opening or closing

Difficulty in chewing

Authorization and Release

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

Name and Date

Signature of patient (or parent/guardian if minor

Doctor's comments:

Name and Date

Signature of patient (or parent/guardian if minor

Upon the completion of the Registration form, please view our Finance Policy and acknowledge that you’ve read and understood the process.

Hours of Operation

Monday: 9 am – 5 pm
Tuesday: 9 am – 5 pm
Wednesday: 9 am – 5 pm
Thursday: 9 am – 5 pm
Friday: 9 am – 5 pm
Saturday: 9 am – 3 pm

Email: [email protected]

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