New Patient Registration First Name(Required) Last Name(Required) Email Address(Required) Date of Birth(Required) Social Security # Address(Required) City, State, Zip(Required) Home Phone # Cell Phone # Employer Work Phone # Work Address Name of Spouse/Parent Spouse/Parent Employer Spouse/Parent Work Phone # Spouse/Parent Work Address Person Responsible for Account Address (if different than patient's) Dental Insurance InformationPrimary Carrier Subscriber's name Subscriber/ID # Group # Subscriber's Employer Subscriber's Date of Birth Secondary Carrier Secondary Subscriber's Name Secondary Policy # Secondary Group # Secondary Subscriber's Employer Secondary Subscriber's Date of Birth Who may we thank for reffering you? Medical HistoryPhysician Name Phone # Do you have any current health problems? Yes No Are you under a physician's care now? Yes No If yes, for what? Are you currently taking any medications? Yes No Do you pre-medicate before dental visits? Yes No If yes, what are the names of your medications? Do you smoke or use any form of tobacco? Yes No Are you pregnant? Yes No Have you ever had, or do you have, any of the following conditions? Heart conditions Inflammatory Disease Surgery Artificial Joint Anemia Stroke Kidney Disease Ulcer Chemotherapy Autoimmune disorders Liver Conditions Blood/Bleeding Disorder Epilepsy Substance Abuse Mental Health Glaucoma Lung Conditions Allergies Diabetes Metabolic Disorders Please describe any conditions checked above:Please describe any other conditions not listed above:Are you allergic to any medications? Yes No If yes, what? Dental HistoryHow long has it been since your last dental visit? Did you have x-rays taken at that visit? Yes No How would you rate your dental health? Excellent Good Fair Poor How often do you brush? How often do you floss? Do you trap food anywhere? Yes No Do your gums bleed or feel irritated/swollen? Yes No Have you had any periodontal/gum treatments? Yes No Are your teeth sensitive to cold, sweets or biting? Yes No Do you get cavities or break teeth often? Yes No Have you had braces/orthodontics? Yes No Do you grind or clench your teeth? Yes No Do you get headaches, ear aches, or neck pain? Yes No Would you like to change anything about your smile? Yes No If yes, what? Are you apprehensive about dental treatment? Yes No Financial Policy(Required) have read and agree to the Archer Dental Financial Policy
