Meet the Doc
Services
All-on-4® Dental Implants
Sinus & Bone Grafting
Wisdom Teeth
Impacted Canines
Tooth Extractions
For Patients
New Patient Registration
Financing by Proceed Finance
Insurance
Contact
Mon - Fri: 8am - 5pm
801-285-9693
435-289-6600
Book Now
Meet the Doc
Services
All-on-4® Dental Implants
Sinus & Bone Grafting
Wisdom Teeth
Impacted Canines
Tooth Extractions
For Patients
New Patient Registration
Financing by Proceed Finance
Insurance
Contact
New Patient Registration Form
1
Patient Personal Information
2
Billing
3
Dental Insurance
4
Secondary Dental Insurance
5
Medical Alerts
6
Questionnaire
Title
Nickname
First and Last Name
(Required)
First
Last
Middle Name
Middle
Address
(Required)
Email
(Required)
Birth Date
(Required)
Month
Day
Year
Age
Health Care Guardian Name
Health Care Guardian Phone #
Extension
Marital Status
Single
Married
Divorced
Widowed
Sex
Male
Female
Not Specified / Unknown
Cell Phone
(Required)
Work Phone
Extension
Home Phone
Driver's License
Emergency Contact
Emergency Phone #
Extension
Student
No
Part Time
Full Time
SSN
School Name
Referral Type
Referred By
Preferred Language
Is patient responsible for paying bills?
(Required)
Yes
No
Title
Nickname
First and Last Name
(Required)
First
Last
Middle Name
Middle
Address
(Required)
Email
(Required)
Birth Date
(Required)
Month
Day
Year
Age
Marital Status
Single
Married
Divorced
Widowed
Sex
Male
Female
Not Specified / Unknown
Cell Phone
(Required)
Work Phone
Extension
Home Phone
Driver's License
SSN
Do you have Primary Dental Insurance?
(Required)
Yes
No
Group No/Name
Insurance Name
Insurance Phone
Extension
Employer Name
Subscriber/Policy Holder First Name
Subscriber/Policy Holder Last Name
(Required)
Subscriber/Policy Holder Address
Relationship to Patient
Self
Spouse
Child
Other
None
Birth Date
Month
Day
Year
Subscriber ID
Do you have Secondary Dental Insurance?
(Required)
Yes
No
Group No/Name
Insurance Name
Insurance Phone
Extension
Employer Name
Subscriber/Policy Holder First Name
Subscriber/Policy Holder Last Name
(Required)
Subscriber/Policy Holder Address
Relationship to Patient
Self
Spouse
Child
Other
None
Birth Date
Month
Day
Year
Subscriber ID
Medical Alerts
Check Here if you'd like to choose no for all med alerts
No to all med alerts
Allergic To
Yes
No
No Known Allergies
Yes
No
Aspirin
Yes
No
Barbiturates / Sleeping Pills
Yes
No
Codeine
Yes
No
Erythromycin
Yes
No
Iodine
Yes
No
Latex Rubber
Yes
No
Local Anesthetics
Yes
No
Metals
Yes
No
Morphine
Yes
No
No Epinephrine
Yes
No
Penicillin
Yes
No
Prior Hepatitis
Yes
No
Sulfa Drugs
Yes
No
Other Narcotics
Yes
No
Check, if applicable
No Change Since Last Recorded
Yes
No
No Known Concerns or Issues
Yes
No
Abnormal Bleeding
Yes
No
AIDS/HIV Infection
Yes
No
Alcohol/Drug Abuse
Yes
No
Angina
Yes
No
Anemia
Yes
No
Ankles Swell
Yes
No
Anorexia
Yes
No
Arteriosclerosis
Yes
No
Arthritis
Yes
No
Asthma
Yes
No
Autoimmune Disease
Yes
No
Bladder Trouble
Yes
No
Blood Clotting Problems
Yes
No
Blood Transfusion
Yes
No
Bulimia
Yes
No
Bronchitis
Yes
No
Cancer / Tumor or Growth
Yes
No
Cardiac Pacemaker
Yes
No
Cardiovascular Disease
Yes
No
Chemotherapy
Yes
No
Chest Pain Upon Exertion
Yes
No
Color Blindness
Yes
No
Congenital Heart Defect
Yes
No
Contact Lenses
Yes
No
Congestive Heart Failure
Yes
No
Damaged Heart Valve
Yes
No
Diabetes
Yes
No
Emphysema
Yes
No
Environmental Allergies
Yes
No
Epilepsy
Yes
No
Fainting Spells
Yes
No
Fever Blisters
Yes
No
Frequent Headaches
Yes
No
Frequently Dry Mouth / Sjogren
Yes
No
Gag Reflex
Yes
No
Gall Bladder Trouble
Yes
No
Hay Fever
Yes
No
Heart Attack
Yes
No
Heart Disease
Yes
No
Heart Murmur
Yes
No
Hepatitis
Yes
No
Herpes
Yes
No
High Blood Pressure
Yes
No
Hives
Yes
No
Jaundice
Yes
No
Joint Replacement
Yes
No
Kidney
Yes
No
Leukemia
Yes
No
Liver Disease
Yes
No
Low Blood Pressure
Yes
No
Lung Disease
Yes
No
Lupus
Yes
No
Mental Health Problems
Yes
No
Mitral Valve Prolapse
Yes
No
Osteoporosis
Yes
No
Pacemaker
Yes
No
Persistent Diarrhea
Yes
No
Premedicate
Yes
No
Radiation Treatment
Yes
No
Rheumatic Fever
Yes
No
Rheumatic Heart Disease
Yes
No
Rheumatoid Arthritis
Yes
No
Seizures
Yes
No
Sexually Transmitted Disease
Yes
No
Shortness of Breath
Yes
No
Skin Rash
Yes
No
Sinus Trouble
Yes
No
Stomach Ulcers
Yes
No
Stroke
Yes
No
Thyroid Problems
Yes
No
Tuberculosis
Yes
No
Unusual Weight Loss
Yes
No
Urinate Frequently
Yes
No
Other
Scanned documents
Max. file size: 20 MB.
Additional Comments
Dental Questionnaire
Name of Previous Dentist
Phone
Do your gums bleed while brushing or flossing?
Yes
No
Are your teeth sensitive to hot, cold or sweets?
Yes
No
Do you get frequent fever blisters, mouth ulcers, or sores on your lips or in your mouth?
Yes
No
Have you ever had burning of the tongue or cracking of the corners of your mouth?
Yes
No
Do you chew/smoke tobacco in any form?
Yes
No
Have you had any head, neck or jaw injuries?
Yes
No
Do you notice popping, clicking or soreness of the jaws or points just in front of the ears?
Yes
No
Do you have difficulty in opening your mouth widely?
Yes
No
Do you clench or grind your teeth?
Yes
No
Have you ever had orthodontic treatment?
Yes
No
If Yes, date of placement
Month
Day
Year
Do you wear dentures or partials?
Yes
No
If Yes, date of placement
Month
Day
Year
Are you happy with your dentures?
Yes
No
Are you having any specific problems with your teeth, gums, or mouth at this time?
Yes
No
Do you have problems with teeth/fillings breaking?
Yes
No
Do you regularly use dental floss?
Yes
No
Do you have, or have you ever been told, that you have Pyorrhea (Periodontal Disease)?
Yes
No
Do you have an unpleasant taste or odor in your teeth/mouth?
Yes
No
Does food catch between your teeth?
Yes
No
Any Disease, Condition or Problem not Listed ? Please list
MEDICAL QUESTIONNAIRE
Emergency contact name
Phone
Emergency contact relationship to patient
Medical Insurance Carrier
Address
Medical Insurance Carrier Phone
Medical Insurance Carrier Employer Name
Medical Insurance Carrier Subscriber Name
Medical Insurance Carrier Subscriber ID #
Medical Insurance Carrier Subscriber Birthdate
Month
Day
Year
Family Physician
Family Physician Phone
Are you currently under care of a Physician?
Yes
No
What is the condition being treated?
Have you had any serious illness, operation or been hospitalized within the past 5 years?
Yes
No
If Yes, what illness or problem?
Are you currently taking any medication?
Yes
No
If Yes, what?
Have you taken bisphosphonates (Fosamax, Boniva, Zometa, Actonel, Didronel, Aredia, Skelid, Reclast)?
Yes
No
Are you currently taking any blood thinners or regularly check your INR?
Yes
No
Do you use alcoholic beverages?
Yes
No
Do you smoke?
Yes
No
Women Only
Women Only
Yes
No
Are you pregnant?
Yes
No
Are you pregnant?
Month
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Are you currently nursing?
Yes
No
Are you on birth control pills / fertility drugs?
Yes
No
Additional Comments
Any Disease, Condition or Problem not Listed ? Please list
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