New Patient Registration Form

I authorize release to my dental benefits plan administrator and the CDA, information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of services described to North Hill Dental and also the use of my signature on all insurance submissions. I hereby assign my benefits, payable from claims submitted electronically, to North Hill Dental and authorize payment directly to them. This authorization shall continue in effect until the undersigned revokes the same.

Dental Anxiety / Sedation

Overall Dental Anxiety Level

None Mild Moderate Severe

Specific Anxiety / Conditions

Dental History and Oral Hygiene Habits

Brush Type

Electric Soft

Floss Type

Normal Motorized

Mouthwash (per day or per week)

Medical History and Health Questionnaire

Date of Last Physical

Physical Condition

Presently in good health Presently under treatment or care of a doctor

Ever hospitalized or had a serious illness?

Yes No

Date of Last Dental Visit

Date of Last Radiograph

Date of Last Cleaning

By submitting this form, you confirm that you have read and understood the Terms and Conditions, Privacy Policy, and Terms of Use of North Hill Dental Center prior to submission, and you agree to them. You can review these documents here: Terms and Policies.

I consent to the collection, use, and disclosure of this personal information for myself, or as the guardian of the patient in this form and accept all policies mentioned above.

By submitting this form, I acknowledge that I have read and agree to the Terms and Conditions, Privacy Policy, and Terms of Use of North Hill Dental Center.

Your Health is Our Top Priority