Austin Family Dental Registration Form Step 1 of 6 16% Patient Information Name* First Middle Last Preferred NameBirth date* MM DD YYYY Sex*MaleFemaleSSN#*Cell PhoneHome Phone*Email* Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Employer/School Name*Work Phone*Parent/Representative*(Person Responsible for Bill)Marital Status*SingleMarriedOtherPartner's Name* First Last Sex*MaleFemaleBirth date* MM DD YYYY How did you hear about us?Would you like access to our online patient portal?*YesNoIf yes, please provide us with your email address on the previous page Insurance Information Do you have insurance?*YesNoSubscriber's Name* First Last Subscriber's Birth date* MM DD YYYY Insurance Carrier*ID Number*Group Number*Secondary Insurance Do you have additional insurance?*YesNoSubscriber's Name* First Last Subscriber's Birth date* MM DD YYYY Insurance Carrier*ID Number*Group Number* In Case of Emergency Contact Name* First Last Phone*Relationship*Work Phone* Consent for Treatment, Insurance, and Financial Policies I hereby authorize the administration of such medications and performance of such diagnostic and therapeutic procedures as may be necessary for proper dental care. The undersigned hereby authorizes Doctor to take x-rays, study models, photographs or any other diagnostic aids deemed appropriate by Doctor to make a thorough diagnosis of the patients’ dental needs. I also authorize Doctor to perform any and all forms of treatment, medication, and therapies that may be indicated and further authorize and consent that the Doctor choose and employ such assistance as he deems fit. I authorize the use of my signature on all insurance claims. I understand that this office does NOT participate with any state insurance program and any costs incurred will be my responsibility. I also understand that responsibility for payment of dental services provided in this office for myself or my dependents is mine, due and payable at the time services are rendered, unless prior financial arrangements have been made. We accept payments in the form of cash, check, Visa, MasterCard, Discover, American Express, and Care Credit. I further understand that a 1.5% finance charge (18% annually) will be added to any balance over 60 days. In the event of default (We) promise to pay legal interest on the indebtedness, together with such collection costs and reasonable attorney fees as may be required to effect collection of this note. We do require a 24-hour notice on all canceled appointments or you may be subject to a fee of $50. Any returned checks are subject to a fee of $30. Signature*Patient/Parent/RepresentativeDate* MM DD YYYY Health & Dental History Medical History Name of Physician*Are you now under the care of a physician?*YesNoIf yes, please explain*Have you ever had any serious illness, operation or accident?*YesNoIf yes, please explain*Are you pregnant, breastfeeding or trying to get pregnant?*YesNoAllergies Latex Codeine Penicillin Local Anesthetic Metals Sulfa Drugs Other Other AllergiesMedications*Please list all medications or drug's and dosages that you are taking.Do you need to take a pre-medication prior to dental treatment?*YesNo Please check if you have had any of the following health problems: Abnormal Bleeding Abnormal Blood Pressure HIV/AIDS Alzheimer's Disease Anemia Arthritis/Gout Artificial Heart Valve Artificial Joint Asthma Breathing Problems Cancer Chemical Dependency Chemotherapy Chest Pains Cold Sores/Fever Blisters Congenital Heart Defect Convulsions Diabetes Emphysema Epilepsy Excessive Bleeding Excessive Urination, Thirst Fainting Spells/Dizziness Glaucoma Hay Fever Heart Attack/Failure Heart Disease Heart Murmur Heart Pacemaker Hemophilia Hepatitis Hepatitis High Cholesterol Hypoglycemia Irregular Heart Beat Jaundice Kidney Problems Leukemia Liver Disease Mental Health Care Osteoporosis Parathyroid Disease Prosthetic Implant Radiation Therapy Renal Dialysis Rheumatic Fever Shingles Sickle Cell Disease Sinus Problems Spina Bifida Stroke Thyroid Problems Tonsilitis Tuberculosis, Lung Disease Tumor Ulcers Venereal Disease Other Other Health Problems* Dental History Reason for today's visit?*Name of former dentist*When was your last dental visit?*How often do you visit the dentist and why?*How often do you brush and floss your teeth?*Are you experiencing discomfort or pain now?*Do you have any old fillings or dental work that trouble you?*Is there anything you would change about you smile?*What things are most important to you about your dental health?*Is keeping your natural teeth important to you?*Do you smoke or use tobacco products?*Check if you have had any of the following dental problems? Bad Breath Bleeding Gums Clicking or Popping Jaw Food Collection Between Teeth Difficulty Opening or Closing Sensitivity to Cold Sensitivity to Hot Sensitivity to Sweets Sensitivity with Biting/Chewing Dry Mouth Grinding Teeth/Clenching Gum Disease Sore, Lump or Growth in Your Mouth Loose Teeth or Broken Fillings Other Other Dental Problems*Are there any other questions or problems you would like assessed today?*YesNoPlease describe:Signature*Date* MM DD YYYY NameThis field is for validation purposes and should be left unchanged.