What is Gum Disease?
  Your Comfort
  Dental Implants
  Other Treatments
  Our Office and Staff
  Our Periodontists
    Pocket Reduction
    Surgery for your smile
    Crown Lengthening
    Bone Regeneration
    Sinus Augmentation
  Your Visit

Your Visit

Good periodontal health begins with you. The first step is the most important. We invite you to call, make an appointment, and find out how we can begin the partnership that will give you lifelong dental health.

Filling out this form below ahead of time will enable you to gather all the necessary information, which lets help you even more. Other items you should obtain ahead of time and bring with you, if appropriate, are
- Any referral form or information from your regular dentist
- Any x-rays
- Information about any dental insurance you have
- A list of any symptoms or signs of gum problems

Patient Registration Form

If you prefer to fill out this form offline and bring it with you to your first visit, click here for a PDF version, or here for a Word version. Click to print pdf Click to print word doc

Personal Information

 First Name:
 Last Name:
 Work Phone:
 Home Phone:
 Cell Phone:
 Date of Birth: 
Insured's Name:
Insurance Company:
Plan Name:
Group #: 
2nd Insurance: 
Plan Name:
Group #:
Emergency Contact: 
Phone Number:
Dentist Name:
Referral Source: 
Dental History

What is the reason for your visit?

(Provide as much information as possible)

When was your last full
mouth x-rays series taken? When was your last cleaning?
Please check all that apply:
     I do not brush regularly
     I do not floss regularly
     My gums bleed
     My teeth are sensitive to hot/cold
     I have discomfort or clicking in my jaw joint
     I do not use powered toothbrush (Sonicare)
     When I eat, food catches between my teeth
     I do not like my smile
Medical History
Please check all that apply:
     I am currently under physician's care
     I have been hospitalized or had a major operation
     I am not in good health
     I bruise easily
     I smoke
     I take medications
     I am allergic to Latex
     I am pregnant or nursing
     I am trying to get pregnant
Physician Name:
Phone Number:
Hospitalization details:   I am allergic to following medications:
Do you have, or have you had any of the following?
Heart Disease
Heart Murmur
Kidney Disease
Rheumatic Fever
Pace Maker
High Blood Pressure
Low Blood Pressure
Blood Disease
Recent Blood Transfusion
  Cortisone Medicine
Stomach/Intestinal Disease
Radiation Treatment
Tumor History
Liver Disease
Drug/Alcohol Addiction
Venereal Disease
Psychiatric Care
Thyroid Disease
Other Comments/Questions: 
  Please indicate your appointment availability
  I would like to schedule:
30 minute consultation (please bring along your x-rays, if available)
Comprehensive one hour dental implant examination

Dental Facts
Certain cheeses, including Cheddar, Swiss and Monterey Jack have been found to protect teeth from decay.
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