Registration Form – Chase Benson DMD

ABOUT YOU:
Today's Date:*
MM slash DD slash YYYY
E-mail Address:*
Name*
First Last
I prefer to be called:
Marital Status
I am:
- Male
- Female
Birthdate:*
MM slash DD slash YYYY
Age:
SS#:*
Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone
Work Phone
Drivers License Number:
Employer
Employer's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
How long there?
Occupation
What is the best time to reach you?

: Hours

Minutes

AM/PM
Which number is best to reach you on?
- Home
- Cell
- Work
Whom may we thank for referring you?
Other family members seen by us:
Previous Dentist:
Date of last dental visit:
MM slash DD slash YYYY
In the event of an emergency, is there someone who lives near you that we should contact?
Emergency Contact Name:
First Last
Emergency Contact Phone:
Relationship:

SPOUSE INFORMATION:
Spouse's Name:
First Last
Spouses Employer:
Spouses Phone:
Spouses SS Number:
Spouses Birthdate:
MM slash DD slash YYYY
Spouses Driver's License Number:
Person Responsible for the Account:*
- I am responsible for the account
- My spouse is responsible for the account
- Other
RESPONSIBLE PARTY INFORMATION:
Name of person responsible for the account
First Last
Responsible Party Phone:
Relationship to Responsible Party
Responsible Party Employer:
Responsible party SS number:
Responsible party Drivers License Number:
Responsible party Billing Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

DENTAL HISTORY:
Why have you come to the dentist today?
Do you require antibiotics before dental treatment?*

Yes

No
Are you currently in pain?*

Yes

No
Do your gums ever bleed?*

Yes

No
Have you ever had a serious / difficult problem associated with any previous dental work?*

Yes

No
Do you now or have you ever experienced pain / discomfort in your jaw joint (TMJ / TMD)?*

Yes

No
Your current dental health is:*

Good

Fair

Poor
Do you like your smile?*

Yes

No
Would you like whiter teeth?*

Yes

No
Would you like fresher breath?*

Yes

No
How many times a week do you floss?*

How many times a day do you bursh?*

Type of bristles?*

Soft

Medium

Hard
Do you smoke or use tobacco in any other form?*

Yes

No
Consent*
I Understand.
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.
I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent
Payment is due in full at the time of treatment unless prior arrangements have been approved.
Consent*
I Understand.
If this office accepts insurance, I understand that I am responsible for payment of service rendered and also responsible for paying any copayment and deductibles that my insurance does not cover.
Our office is HIPAA compliant and committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

WELCOME

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