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799 Farmington Ave.

West Hartford, CT 06119

(860) 236-3271

REQUEST AN APPOINTMENT

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REQUEST AN APPOINTMENT

REGISTRATION AND HEALTH HISTORY FORM

Instructions. Please fill out the information below. Anything marked with * is required. This form cannot be saved, therefore do not close your browser or refresh the page or you will need to re-enter your information. If you have any questions about this form, please call our office at (860) 236-3271.

Step 1 of 4

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General Information
First name*
Last name*
Preferred method for appointment reminders*
- Cell/Text
- Landline
- Work
Cell/Text
Landline
Work
Email*
Date of birth*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State Zip

Employment, Billing and Insurance
Employer name
Employer city
Employer state
Work phone
Responsible billing party name
Responsible billing party address
Street Address Address Line 2 City State Zip
Dental Insurance company name
Dental insurance company address
Street Address Address Line 2 City State Zip
Subscribers employer
Subscribers name
Subscribers date of birth
MM slash DD slash YYYY
Subscribers ID #
Insurance group #
Emergency contact name*
Emergency contact phone*

Medical Information
Please take a moment to let us know about your medical and dental history so we may serve you more effectively by understanding your overall health and well-being.
Primary care physicians name
Primary care physicians address
Street Address Address Line 2 City State ZIP Code
Primary care physicians phone
Are you currently under the care of a physician due to a specific condition?
- Yes
- No
Please describe
Have you been hospitalized within the last 5 years due to a surgery or illness?
- Yes
- No
Please describe
Please list any prescription or non-prescription medications? (include supplements):
Medication
Reason for use
Medication
Reason for use
Medication
Reason for use
Medication
Reason for use
Medication
Reason for use
Do you use tobacco (smoking or chewing)?
- Yes
- No
Have you ever been told to take premedication for dental treatment?
- Yes
- No
Premedication
Reason for use
Do you experience any issue with acid reflux or GERD?
- Yes
- No
WOMEN ONLY: Are you pregnant?
- Yes
- No
Expected due date
MM slash DD slash YYYY
Do you have any allergies to medications (Penicillin or Codeine)?
- Yes
- No
Please provide additional details about allergies. For example, what causes them and what are your reactions.
Please indicate if you have experienced or are under treatment for any of the following:
- Artificial Joints
- Cancer
- Diabetes
- Glaucoma
- Heart Murmur
- Heart Disease
- HIV
- Liver Disease
- Stroke
- Rheumatism
- Sinus Problems
- Asthma
- Epilepsy
- Hepatitis
- Jaundice
- Mental Health
- Respiratory Problems
- Tuberculosis
- Arthritis
- Blood Thinners
- High Blood Pressure
- Kidney Disease
- Pacemaker/Defibrillator
- Rheumatic Fever
- Radiation Treatment
- Venereal Disease
Please list any other conditions, disease or allergies that we should be aware of.
What is the reason for your dental visit today?
When was your last visit to the dentist (if to a different office)?
Are you in any discomfort now?
- Yes
- No
Where? Please describe.
Have you had any complications following dental procedures?
- Yes
- No
When did you last have your teeth cleaned?
MM slash DD slash YYYY

Approximate date is ok.
When did you last have a full mouth x-ray series?
MM slash DD slash YYYY

Approximate date is ok.
When did you last have check-up x-rays?
MM slash DD slash YYYY

Approximate date is ok.
How often do you brush your teeth?
How often do you floss?
Please mark any of the following if they apply and explain below:
- Do your gums bleed when you brush or floss?
- Are your teeth sensitive to cold or hot temperatures?
- Are your teeth sensitive to chewing pressure?
- Have you had adverse reactions to dental anesthetics?
- Are you aware of grinding or clenching your teeth?
- Do you currently have any dental implants, dentures, or partials?
- Do you get headaches?
- Do you experience pain in front of your ears?
- Do you experience any jaw locking that prevents opening or closing?
- Do you experience any clicking or popping from your jaw joint?
Additional details
If you could change anything about your mouth, teeth or smile, what would it be?
Is there anything we haven’t asked that you’d like us to know in order to give you the best possible experience?

Final Information and Agreement
How did you hear about us?*
- Referral (such as a friend or family member)
- Insurance Company
- Outside Sign
- Google
- Social Media
- Postcard or Printed Ad
- Other
Multiple selections are ok.
Referrer name

Please enter the name the person that referred you.
Enter other

Please describe how you found out about us.
AUTHORIZATION
To the best of my knowledge, all of the preceding information is true and correct. If I ever have a change in my medical/dental health, I will inform the office at my next dental appointment without fail. I HEREBY CERTIFY THAT I HAVE READ AND UNDERSTAND THE PREVIOUS INFORMATION AND THAT IT IS ACCURATE AND TRUE TO THE BEST OF MY KNOWLEDGE. I ACKNOWLEDGE THAT PROVIDING INCORRECT AND/OR INACCURATE INFORMATION HAS THE POTENTIAL OF BEING HAZARDOUS TO MY HEALTH. I AUTHORIZE THE DIAGNOSIS OF MY DENTAL HEALTH BY MEANS OF RADIOGRAPHS, STUDY MODELS, PHOTOGRAPHS, OR OTHER DIAGNOSTIC AIDS DEEMED APPROPRIATE. I AUTHORIZE THE DENTIST TO RELEASE ANY INFORMATION INCLUDING THE DIAGNOSIS AND RECORDS OF TREATMENT OF EXAMINATION FOR MYSELF AND MY DEPENDENT(S) TO THIRD-PARTY INSURANCE CARRIERS, PAYORS, AND/OR HEALTHCARE PRACTITIONERS. I AUTHORIZE THE PAYMENT FROM MY INSURANCE CARRIER TO SUBMIT PAYMENT DIRECTLY TO THE DENTIST OR DENTAL PRACTICE TO BE APPLIED DIRECTLY TO ANY OUTSTANDING BALANCE ON MY ACCOUNT. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ANY OUTSTANDING BALANCE FOR SERVICES PROVIDED THAT ARE NOT FULLY COVERED BY INSURANCE, AND I MAY BE BILLED FOR THIS REMAINING BALANCE. I CONSENT AND AGREE TO BE FINANCIALLY RESPONSIBLE FOR PAYMENT OF ALL SERVICES RENDERED ON MY BEHALF AND OF MY DEPENDENTS (IF ANY). SIGNATURE OF PATIENT, PARENT, OR GUARDIAN:

West Hartford Dentist - Avenue Dental Arts - Outside Office@2x

CONTACT US

AVENUE DENTAL ARTS

799 Farmington Ave.
West Hartford, CT 06119

OFFICE HOURS

Extended hours for your convenience!

Monday: 8am-5pm
Tuesday: 8am-6pm
Wednesday: 8am- 5pm
Thursday: 7am- 5pm
Friday: By appointment only

Cosmetic Dentistry
Dental Crowns & Bridges
Dental Implants
Dentures

Emergency Dentistry
General & Family Dentistry
Invisalign
Periodontics

Porcelain Veneers
Root Canals
Sedation Dentistry
Sleep Apnea

Teeth Whitening
TMJ/TMD Treatment
Tooth Extractions

Tel: (860) 236-3271 | 799 Farmington Ave. West Hartford, CT 06119

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