Patient Registration and Medical History

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Please fill out the form in its entirety for our records. This form is secure and will not be shared with anyone but employees at Westwood Village Dental, located in Westwood, NJ. Upon arriving at the office, you will still need to provide us with your social security number, your dental insurance's group number, your spouse's social security number (if applicable), and your spouse's dental insurance's group number (if applicable). If your family has decided to join our practice, please fill out an individual form for each person joining us. Thank you for taking the time to fill out this form prior to your first visit!

Email *

Patient Information

Please complete all parts of this portion of the form.

Patient Name *

Street Address, City, State, Zip Code *

Phone Number *

Sex *

Male

Female

Prefer not to say

Birth date *

YYYY

Social Security

Relationship Status

Single

Married

Widowed

Separated

Divorced

Domestic Partner

Clear selection

Employer *

Occupation

Business Address

Dental Insurance Company *

Subscriber Name *

Subscriber ID# *

Group Name&Number

Subscriber date of birth *

In case of emergency, who should be notified? (please include name and phone number) *

Relationship to Patient *

Who may we thank for referring you?

Medical History

Please complete all parts of this portion of the form.

Physician's Name

Date of Last Physical

YYYY

Have you ever had any of the following? (check all that apply) *

Heart Murmur

High Blood Pressure

Low Blood Pressure

Circulatory Problems

Nervous Problems

Radiation Treatment

Artificial Heart Valve/Joints

Recent Weight Loss

Back Problems

Diabetes

Respiratory Disease

Epilepsy

Headaches

Hepatitis, Jaundice, Liver Disease

Cancer

Psychiatric Care

Mitral Valve Prolapse

General Allergies

Blood Disease

Arthritis

Special Diet

Swollen Neck Glands

Rheumatic Fever

Sinus Problems

AIDS/HIV

Thyroid Disease

Stroke

Ulcer

Venereal Disease

Chemical Dependency

Hemophilia

Pins, Artificial Joints or Replacements

Periodontal Disease, "Bleeding Gums", or History of Surgery

None

Other:

Required

Option 1

Clear selection

Are you allergic to any of the following? (check all that apply) *

Anesthetic

Aspirin

Codeine

Ibuprofen

Iodine

Latex

Penicillin

Sulfa

None

Other:

Required

Do you have any drug allergies or have you ever had an adverse reaction to any medication? *

Yes

If yes, please describe:

Have you ever responded adversely to medical or dental treatment? *

Yes

Are you taking any medication at this time? *

Yes

If yes, please describe:

Are you presently under a physician's care? *

Yes

If yes, please specify for what condition(s):

If patient is a child, what is his/her weight?

(Women only) Do you suspect that you are pregnant?

Yes

Maybe

Clear selection

(Women only) Are you nursing?

Yes

Clear selection

(Women only) Are you using contraceptives?

Yes

Clear selection

Tobacco use? If so, what kind and how much?

Is there anything else we should know about your medical history? *

Reason for today's visit / Are you in pain?

Do you have a Panoramic x-ray or Full Mouth x-rays that are less than 5 years old?

Yes

Maybe

Clear selection

Do you have BiteWing x-rays that are less than 1 year old?

Yes

Maybe

Clear selection

Name of former dentist

City/State

Date of last cleaning and exam

YYYY

A copy of your responses will be emailed to the address you provided.

Submit

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