Adult Patient Registration

Complete the secure registration form before your visit.

Step 1 of 5Patient Info

Patient InfoMedical HistoryDental HistoryFinancialPrivacy & Consent

Patient Health Record / Update

Name *

Date

SS#

Age

Date of Birth

Address

Home Address

City

Zip

Contact Information

Home Phone

Cell Phone

Work Phone

May we leave a message?

Yes

No

Email

Emergency Contact

Name

Phone Number

Insurance Information

Insurance Co

Name of Insured

Employer

ID#

Gp#

DOB of Insured

How Did You Find Us?

Billboard

Website

Church Bulletin

Pinecrest Academy

Patient

Other

Medical Basics

Date of Last Physical Exam

Name of Physician

Pharmacy Name / Number

Have you been hospitalized or under a physician's care in the past 2 years?

Yes

No

Any major surgeries?

Yes

No

Knee or Hip Replacement?

Yes

No

Do you take antibiotics prior to dental work?

Yes

No

Pregnant or Nursing?

Yes

No

Do you take birth control pills?

Yes

No

Do you take osteoporosis meds (Fosamax, Boniva, or other bisphosphonates)?

Yes

No

Allergic to:

Latex

Local Anesthetics

Penicillin

Aspirin

NSAIDS

Codeine

Foods

Please list ALL medications and supplements:

Upload your documents:

Driver's License

Tap to upload

Insurance Front

Tap to upload

Insurance Back

Tap to upload

Medication List

Tap to upload