New Patient Registration

Stone Oak Aesthetic Dentistry

Patient Name
First Name
Middle Name
Last Name
Address
Street Address
Street Address Line 2
City
State
Postal
Home Phone
Occupation
Work Phone
Cell Phone
Email
Primary Email
Birth Date
Sex
Male
Female
Others
This field is required.
Marital Status
Single
Married
Separated
Widowed
This field is required.
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Emergency Contact Relationship to Patient
Whom may we thank for referring you to our office

Responsible party
(if someone other than the patient)
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State
Postal
Home Phone
Work Phone
Cell Phone
Email
Primary Email

Primary Dental Insurance Information
Name of Insured
First Name
Last Name
Insured Birth Date
Relationship to insured
Self
Spouse
Child
Other
This field is required.
Insured Social Security Number
Member ID Number
Group Number
Employer
Insurance Company
Insurance Claiming Address
Street Address
Street Address Line 2
City
State
Postal

Secondary Dental Insurance Information
Insured Birth Date
Relationship to insured
Self
Spouse
Child
Other
This field is required.
Insured Social Security Number
Member ID Number
Group Number
Employer
Insurance Company
Insurance Claiming Address
Street Address
Street Address Line 2
City
State
Postal

Medical History
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.
Are you under a physician's care now
Yes
No
This field is required.
If yes, please explain:
Have you ever been hospitalized or had a major operation?
Yes
No
This field is required.
If yes, please explain:
Have you ever had a serious head or neck injury?
Yes
No
This field is required.
If yes, please explain:
Are you taking any medications, pills, or drugs
Yes
No
This field is required.
If yes, please explain:
Do you take vitamins or herbal supplements?
Yes
No
This field is required.
Do you take, or have you taken Phen-Fen or Redux?
Yes
No
This field is required.
Have you ever taken Fasamax, Boniva. Actonel or any other medications containing bisphesphonates?
Yes
No
This field is required.
Are you on a special diet?
Yes
No
This field is required.
Do you use tobacco?
Yes
No
This field is required.
Do you use controlled substances?
Yes
No
This field is required.
Are you allergic to any of the following?
Aspirin
Penicillin
Codeine
Local Anesthetics
Acrylic
Metal
Latex
Sulfa drugs
Other
N/A
This field is required.
If Other, please explain
Women are you?
Pregnant/Trying to get pregnant?
Yes
No
This field is required.
Taking oral contraceptives?
Yes
No
This field is required.
Nursing?
Yes
No
This field is required.
If yes, please explain:

Do you have, or have you had, any of the following?
AIDS/HIV Positive
Alzheimer's Disease
Anaphylaxis
Anemia
Angina
Arthritis/Gout
Artificial Heart Valve
Artificial Joint
Asthma
Blood Disease
Blood Transfusion
Blood Transfusion
Bruise Easily
Cancer
Chemotherapy
Chest Pains
Cold Sores/Fever Blisters
Congenital Heart Disorder
Convulsions
Cortisone Medicine
Diabetes
Drug Addiction
Easily Winded
Emphysema
Epilepsy or Seizures
Excessive Bleeding
Excessive Thirst
Fainting Spells/Dizziness
Frequent Cough
Frequent Diarrhea
Frequent Headaches
Genital Herpes
Glaucoma
Hay Fever
Heart Attack/Failure
Heart Murmur
Heart Pacemaker
Heart Trouble/Disease
Hemophilia
Hepatitis A
Hepatitis B or C
Herpes
High Blood Pressure
High Cholesterol
Hives or Rash
Hypoglycemia
Irregular Heartbeat
Kidney Problems
Leukemia
Liver Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse
Osteoporosis
Pain in Jaw Joints
Parathyroid Disease
Psychiatric Care
Radiation Treatments
Recent Weight Loss
Renal Dialysis
Rheumatic Fever
Rheumatism
Scarlet Fever
Shingles
Sickle Cell Disease
Sinus Trouble
Sleep Apnea/Snoring
Spina Bifida
Stomach/Intestinal Disease
Stroke
Swelling of Limbs
Thyroid Disease
Tonsillitis
Tuberculosis
Tumors or Growths
Ulcers
Venereal Disease
Yellow Jaundice
This field is required.
Have you ever had any serious illness not listed above?
Yes
No
This field is required.
Comments
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.
Signature
Signature is mandatory.

Dental History
Patient Name
First Name
Last Name
What concerns you most about your teeth?
Are you presently in any dental pain?
Yes
No
This field is required.
if yes, please explain:
Have you ever experienced any unfavorable reaction to dentistry
Yes
No
This field is required.
if yes, please explain:
Have you ever lost or chipped any teeth?
Yes
No
This field is required.
Have there been any injuries to your face, mouth, or teeth?
Yes
No
This field is required.
Is any part of your mouth sensitive to hot, or cold?
Yes
No
This field is required.
Is any part of your mouth sensitive to pressure?
Yes
No
This field is required.
Are you a mouth breather, or do you snore?
Yes
No
This field is required.
Do your teeth or jaws ever feel uncomfortable when waking in the morning?
Yes
No
This field is required.
Are you aware of your jaws clicking or popping?
Yes
No
This field is required.
Are you aware of clenching your teeth during the day?
Yes
No
This field is required.
Have you ever been told that you grind your teeth?
Yes
No
This field is required.
Do you experience headaches or migraines?
Yes
No
This field is required.
Do you often experience bad breath?
Yes
No
This field is required.
Do you wear any oral appliance?
Yes
No
This field is required.
Have you ever had a sleep study?
Yes
No
This field is required.
If yes, do you use a CPAP machine?
Yes
No
This field is required.
Signature
Signature is mandatory.

Stone Oak Aesthetic Dentistry Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Patient Name
First Name
Last Name
Signature
Signature is mandatory.

Stone Oak Aesthetic Dentistry Financial Policy
Patient Name
First Name
Last Name
Signature
Signature is mandatory.

Photo Consent Form
Patient Name
First Name
Last Name
Signature
Signature is mandatory.

Authorization Form
Name
First Name
Last Name
Relation to patient
Name
First Name
Last Name
Relation to patient
Signature
Signature is mandatory.