New Patient Registration Form

Getting Started With Your Visit

Welcome to Joobbani Dental Office. To help us prepare for your visit and provide you with the best possible care, please complete the New Patient Registration Form below. The form includes your contact information, dental and medical history, insurance details, and any concerns you may wish to discuss with our dental team. All information provided will remain confidential and will help us better understand your oral health needs before your appointment. Please complete all required sections and submit the form once finished.

Please complete all required sections and submit the form once all information has been provided.

Contact Information

Patient's Last Name*

Patient's First Name*

Middle Initial

Preferred Name / Nickname

Patient Sex

MaleFemale

Date of Birth*

Responsible Party's Name (if not patient)

Relationship to Patient

Home Address*

City*

State*

ZIP*

Mobile Number*

Home Number

Work Number

Email*

Who may we thank for referring you to our office?

Which other family members are patients at this office?

Insurance Information

Subscriber's Name

Subscriber's Date of Birth

Insurance Company Name

Subscriber ID Number

Group ID Number

Name of Subscriber's Employer

Subscriber's Relationship to Patient

Emergency Contact Information

Name of Emergency Contact*

Relationship to Patient*

Home Telephone Number

Work Telephone Number

Cell or Other Telephone Number*

Dental History & Treatment Options

Date of Last Dental Visit

Former Dentist

Date of Last X-rays

Office Number

Do you feel that your mouth or jaw functions properly?

YesNo

Are you happy with the appearance of your teeth/smile?

YesNo

Are all of your teeth in alignment?

YesNo

Do you have any old fillings, crowns, or dental treatments that concern you?

YesNo

Please let us know if you would like information about any of the following:

Check if you have had problems with any of the following:

Would you like to change anything about your teeth/smile? Is there anything else you would like to discuss today?

Are you fearful of dental treatments?

YesNo

If yes, rate your fear level from 1 to 10

What is the trigger for your fear?

Other Fear Trigger

Medical History

Please check any of the following which apply to you:

Please explain any disease, condition, or problem not listed above:

Medication / Substance History

Women Only

If you are not a woman or the following questions do not apply to you, please choose N/A for each question.

Are you pregnant?

YesNoN/A

Are you nursing?

YesNoN/A

Are you trying to get pregnant?

YesNoN/A

Are you using birth control pills?

YesNoN/A

Medical Information Questions

Have you had a joint replacement?

YesNo

If yes, date

Site

Any complications?

Have you had a serious illness, operation, or been hospitalized in the past?

YesNo

If yes, please explain

Have you ever had a blood transfusion?

YesNo

If yes, date and reason

Do you use tobacco products?

YesNo

If yes, what type?

How often?

Allergies

Please check all that apply:

Other Antibiotics

Other Allergies

To all yes responses please specify allergy type and severity:

Do you carry an inhaler?

YesNo

Do you carry an Epi-Pen?

YesNo

Medications

Please list all current prescription medications, over-the-counter medications, and supplements:

Consent & Confirmation

I certify that I have read and understand the above and that the information given on this form is accurate.

Print Name*

Please sign below:

Date*

New Patient Registration Form

Getting Started With Your Visit