Perio Specialist - New Patient Registration

How fearful are you of dental treatment (10 being the most)?

Have you ever had braces, or had your bite adjusted?

Yes

Have you ever had gum surgery?

Yes

Have you ever had deep cleaning of your teeth?

Yes

Do you have any dental implants in your mouth?

Yes

Date of last deep cleaning

I certify I have read and I understand the questions. I acknowledge my questions have been answered to my satisfaction. I will not hold my doctor, or any other member of his/her team, responsible for any errors or omissions that I have made in the completion of this form.

I permit the office to communicate with me via text message.

If I have dental insurance, my signature on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment to this doctor named of the benefits otherwise payable to me.

I hereby acknowledge a copy of the Notice of Privacy Practices has been made available to me (see form on website). I have been given the opportunity to ask any questions I may have regarding this Notice.

New Patient Registration

Patient Information

Preferred Pharmacy

Dental History