Fill Out Form Patient Registration

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429 N. Ferncreek Avenue, Orlando, FL 32803

Make a Payment (407) 777-2071

New Patient Registration Fields marked with * are required

First Name *

Last Name *

Preferred Name

SSN

Date Of Birth *

Driver's License Number

Gender * Male Female Non-Binary

Address *

Address (optional)

City *

State *

Zip *

Primary Phone *

Work Phone

Emergency Phone

Employer

Occupation

Employment Status

Previous Dentist

Referred By * Google Social Media Patient Other

If Other, Please Specify

New Patient Questionnaire Fields marked with * are required

Reason for this appointment

Date of your last dental visit *

What was your last visit for? *

Date of last dental cleaning

Do you have a specific dental concern? Please describe:

Have you ever had periodontal problems? Yes No

Do you like your smile? (Rate 1-10)

What would you change about your smile:

Make it straighter

Make it whiter

Fill my spaces

Does food catch between your teeth or do you have areas that are difficult to floss? Yes No

Does loss of teeth run in your family? Yes No

Do you have clicking, popping or discomfort in the jaw joint? Yes No

Do you grind your teeth? Yes No

Have you had braces (orthodontia)? Yes No

Why did you leave your last dental office?

Rate your previous dental office experience: (1-10)

Do you smoke/chew tobacco, if so how frequently?

Have you had cavities in the past? Yes No

Do you snack between meals? Yes No

Do you experience heartburn or acid reflux? Yes No

Do you drink soda, bottled water, sports drinks, coffee or tea? Yes No

Do you wear a retainer, mouth guard, partial denture, or Invisalign trays? Yes No

Does your mouth feel dry? Yes No

Do you take any medications that cause dryness? Yes No

Responsible Party (if someone other than patient) Fields marked with * are required

Relation To Patient

First Name

Last Name

Preferred Name

Gender Male Female

Date Of Birth

Driver's License Number

SSN

Address

Address (optional)

City

State

Zip

Primary Phone

Work Phone

Emergency Phone

Employer

Occupation

Employment Status

Referred By

Insurance Information Fields marked with * are required

Insurance Company Name

SSN or ID Number

Group Number

First Name

Last Name

Date of Birth

Gender Male Female

Address

Address (optional)

City

State

Zip

Employer

Occupation

Employment Status

Secondary Insurance Information Fields marked with * are required

Insurance Company Name

SSN or ID Number

Group Number

First Name

Last Name

Date of Birth

Gender Male Female

Address

Address (optional)

City

State

Zip

Employer

Occupation

Employment Status

Health History Fields marked with * are required

Have you been hospitalized in the last two years? * Yes No

For What?

Have you ever been hospitalized? * Yes No

For What?

Are you currently being treated by a physician? * Yes No

If Yes:

Have you ever had a serious head or neck injury? * Yes No

If Yes:

Are you taking any medications, pills, or drugs? * Yes No

If Yes:

Do you take, or have you taken, Phen-Fen or Redux? * Yes No

If Yes:

Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? * Yes No

If Yes:

Are you on a special diet? * Yes No

If Yes:

Do you use tobacco? * Yes No

Do you use controlled substances? * Yes No

If Yes:

Women: Are you pregnant / Trying to get pregnant? * Yes No

Nursing? * Yes No

Taking oral contraceptives? * Yes No

Are you allergic to any of the following? Fields marked with * are required

Aspirin * Yes No

Penicillin * Yes No

Codeine * Yes No

Acrylic * Yes No

Metal * Yes No

Latex * Yes No

Sulfa Drugs * Yes No

Local Anesthetics * Yes No

Other? * Yes No

If Yes:

Sleep Medicine Questionnaire Fields marked with * are required

Have you been diagnosed with sleep apnea? Yes No

Do you have a CPAP? Yes No

If so, how many nights per week do you wear your CPAP?

On nights when you wear your CPAP, how many hours do you typically wear it?

Do you snore or have you ever been told that you snore, stop breathing, or gasp for air when you sleep? Yes No

After a typical night's sleep, do you feel refreshed? Yes No

Have you been diagnosed with atrial fibrillation (AFib)? Yes No

If you have high blood pressure, is it well-controlled? Yes No

If no, how many blood pressure medications are you currently taking?

Do you have, or have you had, any of the following? Fields marked with * are required

AIDS/HIV Positive

Alzheimer's Disease

Anaphylaxis

Anemia

Angina

Arthritis/Gout

Artificial Heart Valve

Artificial Joint

Asthma

Blood Disease

Blood Transfusion

Breathing Problems

Bruise Easily

Cancer

Chemotherapy

Chest Pains

Cold Sores / Fever Blisters

Congenital Heart Disorder

Convulsions

Yellow Jaundice

Cortisone Medicine

Diabetes

Drug Addiction

Easily Winded

Emphysema

Epilepsy or Seizures

Excessive Bleeding

Excessive Thirst

Fainting Spells / Dizziness

Frequent Cough

Frequent Diarrhea

Frequent Headaches

Genital Herpes

Glaucoma

HayFever

Heart Attack / Failure

Heart Murmur

Heart Pacemaker

Heart Trouble / Disease

Sleep Apnea

Hemophilia

Hepatitis A

Hepatitis B or C

Herpes

High Blood Pressure

High Cholesterol

Hives or Rash

Hypoglycemia

Irregular Heartbeat

Kidney Problems

Leukemia

Liver Disease

Low Blood Pressure

Lung Disease

Mitral Valve Prolapse

Osteoporosis

Pain In Jaw Joints

Parathyroid Disease

Psychiatric Care

Snoring

Radiation Treatments

Recent Weight Loss

Renal Dialysis

Rheumatic Fever

Rheumatism

Scarlet Fever

Shingles

Sickle Cell Disease

Sinus Trouble

Spina Bifida

Stomach / Intestinal Disease

Stroke

Swelling Of Limbs

Thyroid Disease

Tonsillitis

Tuberculosis

Tumors or Growths

Ulcers

Venereal Disease

Have you ever had any serious illnes not listed? * Yes No

If Yes:

Comments

Did you know that we offer cosmetic and therpuetic Botox and Dermal Filler? If you are interested, please check the boxes below. Fields marked with * are required

Forehead Lines

Lip appearance and texture

Frown lines

Thin Lips

Crow's feet lines

Double chin

Flattened cheeks / sunken cheeks

Thinning or inadequate lashes

Lines and wrinkles around the nose and mouth

Skin appearance and texture

Terms And Conditions Fields marked with * are required

Terms * I understand that the information that I have given today is correct to the best of my knowledge and that providing incorrect information can be dangerous to my (or patient's) health. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.

Release Authorization Fields marked with * are required

I authorize Dr. Trivedi DMD, FAGD and office staff to release or request my medical and/or billing information to the following individuals:

HIPAA and Privacy Practices Consent Fields marked with * are required

HIPAA Consent * I give this practice/ clinic my consent to use or disclose my protected health information to carry out my treatment, to obtain payment from insurance companies, and for health care operations like quality reviews.
I give this practice consent to leave messages with household members and answering machines when necessary.
I have been informed that I may review the practice's "Notice of Privacy Practices" (for a more complete description of uses and disclosures) before signing this consent.
I understand that this practice has the right to change their Privacy Practices and that I may obtain any revised notices at the practice.
I understand that I have the right to request a restriction of how my protected health information is used. However, I also understand that the practice is not required to agree to the request. If the practice agrees to my requested restriction, they must follow restriction(s).
I also understand that I may revoke this consent at any time by making a request in writing, except for information already used or disclosed.

Signature Fields marked with * are required

Date: 12/30/2024

HOURS OF OPERATION

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