Patient Registration Form

Name *

First

Last

Street Address *

City *

Zip Code *

Home Phone

Cell Phone

Work Phone

Email *

Date of Birth

Gender

Male
Female

Marital Status *

Primary Dental Insurance Name

Subscriber Name & Address (if not the patient)

Subscriber Date of Birth

Subscriber Employer

Subscriber's ID #

Group #

Dental Insurance Address & Phone Number

Emergency Contact (First & Last Name)

Phone

Referred By

Name of Dentist (if you have one)

Is this visit the result of an injury?

If yes, what was the injury?

Have you previously had scaling and root planing also known as “deep cleaning” with anesthetic? If so, when?

Have you had any complication with previous dental treatment?

Do you consider yourself a nervous person when it comes to dental treatment?

Do you feel you have bad breath?

Do your gums bleed?

Have you noticed any loose teeth? If yes, how long?

Do you think your teeth are affecting your general health in any way?

Are you satisfied with the appearance of your teeth?

Do you have any sensitive teeth?

Do you have any suggestions on how we could make your periodontal treatment less stressful and more comfortable for you?

Pharmacy Name

Pharmacy Location

Pharmacy Phone #

The success of periodontal therapy is dependent on many factors including the severity of the periodontal destruction, the patient’s general physical status, and the patient’s ability and willingness to perform proper oral hygiene and stay on a recall program after active treatment. As with treatment of any complex condition, especially where drugs and surgical procedures are being used, unusual and unanticipated problems can arise, such as bleeding, prolonged numbness, sensitivity to medications, sensitive or loose teeth and pulp damage. We will make every effort to keep you informed of the treatment necessary for you. Feel free to ask questions at any time. Your involvement and understanding are very important in the long term success of your periodontal therapy. In implant surgery the potential risks and complications involved could include pain, swelling, infection, and discoloration. Numbness of the lip, tongue, chin, cheek, or tooth may occur. The exact duration may not be determinable and may be irreversible. Also possible are inflammation, injury to teeth, bleeding, bone fractures, sinus infection, and delayed healing. In some instances, implants fail and must be removed. If there is any further information that you feel we should be aware of please write it here.

Name of Primary Care

List all medical conditions you have been diagnosed with (ex: Acid Reflux, Depression, Diabetes, High BP, Osteoporosis, Thyroid Disease, Cancer Type)

Have you had surgery or x-ray treatment for a tumor, growth, or other condition of your head, mouth, or lips?

List any serious illness or surgery you have had in the past 6 months

Have you had abnormal bleeding associated with previous surgery, tooth extraction, or trauma?

List all drugs and supplements you are taking

Have you ever been diagnosed with osteoporosis, or taken any bone altering/preserving medications (oral or IV)?

Check if you are ALLERGIC or have an adverse reaction to any of the following:

If you checked "Other" above, please list them here:

Have you ever been warned against taking any drug or medicine for your own personal health?

If so, what drug and why?

Are you routinely pre-medicated with an antibiotic for a dental procedure?

What is the estimation of your general health?

Do you smoke or use smokeless tobacco (vaping)?

If so, how much?

How many years?

Have you EVER smoked or used smokeless tobacco (vaping)?

I give permission for North Raleigh Periodontics to disclose my personal health information to the following persons (spouse, sibling, parent, child, friend, doctor's office)

Information that can be disclosed (check all that apply):

Appointment dates & times
Treatment plans & referals
Financial & billing information
Any other pertinent dental health informaion related to treatment at this office
None of the above

I understand that this permission will remain in effect unless a written cancellation has been provided to North Raleigh Periodontics

Yes
No

Occasionally we use patients' intra-oral photos (photos that are taken of your teeth, gums, and oral tissue) on our social media. Do we have your permission to use or share your photos on our social media platforms?

Yes
No

I have viewed a copy of this office’s Notice of Privacy Practices (hyperlinked at the top of this page and directly below):

Yes
No

Privacy Practices

I have read and agreed to the Cancellation Policy & Payment Policy (hyperlinked at the top of this page and directly below):

Yes
No

Cancellation Policy

Payment Policy

I hereby authorize North Raleigh Periodontics or designated staff to take x-rays, study models, photographs and any other diagnostic aids deemed appropriate by our office to make a thorough diagnosis of dental needs.

Yes
No

By checking "I AGREE" below, I consent to this as an electronic signature and agree that all information in this form is correct and done solely by me. *

I agree

Patient's Full Legal Name *

Today's Date *

Parent or Responsible Party

Relationship to Patient

Uploading your insurance card prior to your first visit will ensure that the insurance verification process goes smoothly and is completed before you walk through our doors. We are still required to see your insurance card at the time of your visit. Please don't forget to bring it. You can upload either JPEG or PDF file. (front & back)

Drag & Drop Files, Choose Files to Upload

Front of Card

Drag & Drop Files, Choose Files to Upload

Back of Card