Arcadia Perio Care


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	• 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.

• required
Personal Information

• First Name:

• Last Name:

• Address:

• City:

• State/Zip:

• Work Phone:

• Home Phone:

• Cell Phone:

• Email:

• Date of Birth:

Spouse/Partner:

Employer:

Insured's Name:

Relationship:

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
Diabetes
Stroke
Heart Murmur
Epilepsy
Kidney Disease
Rheumatic Fever
Arthritis
Pace Maker
High Blood Pressure
Low Blood Pressure
Blood Disease
Recent Blood Transfusion
Asthma

Cortisone Medicine
Tuberculosis
Stomach/Intestinal Disease
Ulcer
AIDS/HIV +
Radiation Treatment
Tumor History
Chemotherapy
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.