New Patient Registration

Please print, fill out all information and bring this form and your insurance card on the first appointment.
You may fax it to us prior to your appointment: 301-871-0750

Name___________________________________ Date of Birth____________ Date ___________S M W D

Home Address _______________________________City ________________State ______Zip Code______

Home Phone __________________Cell Phone ___________________E-mail________________________

Employer _________________________________________Occupation____________________________

Address ________________________________________________Work Number____________________

Dental Insurance Program _______________________________Local Phone No.____________________

Insurance Group/ID Number _____________________________Social Security #____________________

Person Responsible for  Account ____________________Address__________________________________

City ____________________________________State _______________Zip Code____________________

Referred By ______________________________Remarks_______________________________________

Medical History

Physician _________________________________________________Telephone_____________________

Address_______________________________________________________________________________

Current Medications_____________________________________________________________________

Allergies_______________________________________________________________________________

Are you under a physician's care now? ______If so, please give reason for treatment__________________

Have you ever taken Fen- Phen  /Redux?_______________________________________________________

Please circle any illnesses you have ever had:

Rheumatic fever	Diabetes	Anemia	Kidney or Liver	Other
Infectious hepatitis	Epilepsy	Heart Trouble	Asthma
Tuberculosis	High Blood Pressure	Glaucoma	HIV Infection

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

Have you ever had trouble with prolonged bleeding after surgery?_________________________________

Have you ever had any unusual reaction to an anesthetic or drug (like penicillin)?_____________________

Is there any other information that should be known about your health? ____________________________

About previous dental visits? ______________________________________________________________

Signature_____________________________________________



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