New Patient Registration

First Name*

Last Name*

Date of Birth*

Sex*

• Male
• Female
• Prefer not to say

Phone Number*

Email Address

Street Address

Preferred Language

• English
• Vietnamese / Tieng Viet
• Spanish / Espanol
• Other

Emergency Contact Name

Emergency Contact Phone

When was your last dental visit?*

• Within the last 6 months
• 6 months to 1 year ago
• More than 1 year ago
• Never been to a dentist

Main reason for this visit*

• Cleaning & check-up
• Tooth pain or sensitivity
• Broken or chipped tooth
• Cosmetic concern
• Dentures or partials
• Other

Describe any current dental concerns

Previous Dentist Name (if any)

Do you have any medical conditions?*

• Yes
• No

Select all that apply

• Heart disease
• High blood pressure
• Diabetes
• Asthma
• Bleeding disorder
• Hepatitis
• HIV/AIDS
• Cancer (current or past)
• Thyroid disorder
• Joint replacement
• Other (describe below)

Please describe other conditions

Are you currently taking any medications?*

• Yes
• No

List your current medications

Do you have any allergies?*

• Yes
• No

List your allergies

Are you currently pregnant or nursing?*

• Yes
• No

How will you be paying?*

• Medi-Cal (Denti-Cal)
• Private dental insurance
• Self-pay (no insurance)
• Other / not sure

Insurance Company*

Member ID*

Group Number

Medi-Cal Beneficiary ID (BIC Number)*

Electronic Signature*

Signature