We would like to welcome you as a patient at Dr. John W. Ringo Family Dentistry. At the initial appointment we will perform a comprehensive examination and take a full mouth series of x-rays as needed. We will assess your current dental needs and develop a treatment plan with you.

Dr. John W. Ringo Family Dentistry is committed to providing the highest quality of dental care in a pleasant, comfortable environment. We are sensitive to patients’ concerns and encourage questions about any proposed treatment. Our practice places a strong emphasis on preventative dentistry. We have an expectation that our patients follow an ongoing schedule of continuing care – including regular check-ups, preventative treatment (i.e. teeth cleaning sealants, fluoride treatment) and diagnostic x-rays as needed. We also have an expectation that our patients will follow through with recommended dental procedures that my staff or I deem necessary for maintaining good oral health.

We look forward to seeing you soon.

Warm Regards,

John W. Ringo, DDS PC and Associates LTD

Click here to print out a New Patient Form

Patient Registration

Date:

Patient Last Name:
Patient First Name and Middle Initial:
Social Security Number:
Birth Date:

Sex: MaleFemale

Email Address:
Cell Phone:

Home Phone:

Address: City, State, Zip Code:
Patient Employed By:
Business Phone:

Spouse's Name:
Spouse's SSN:

Spouse's Birthdate:

Spouse Employed By:
Spouse's Business Phone:

Person to contact for emergency:
Address: City, State, Zip Code:
Home Phone:

Cell Phone:

Work Phone:

Referred By (Who may we thank for referring you?):


Primary Insurance

Name of Person financially responsible for the account:
Primary Dental Insurance Company:
Secondary Dental Insurance Company:
Best Time to be Reached at Home:
Preferred Appointment Times:


Authorization

* I authorize the dentist to perform an examination, diagnostic procedures and prophylaxis as may be necessary for proper dental evaluation.

* I authorize release of any information concerning my (or my child's) health care, advice and treatment to another dentist.

* I authorize my insurance company to pay to the dentist or dental group all insurance benefits otherwise payable to me for services rendered.

* I authorize the use of this signature on all insurance submissions.

* I authorize the dentist to release all information necessary to secure the payment of benefits.

* I understand that I am financially responsible for all charges whether or not paid by insurance.

Signature (type name):
Date:


Minor

If you are under the age of eighteen years

Name of Father:
Father's SSN:

Father's Birthdate:

Father Employed By:
Father's Business Phone:

Name of Mother:
Mother's SSN:

Mother's Birthdate:

Mother Employed By:
Mother's Business Phone:


Medical History

Name and Address of Physician:
When was your last examination:

Are you now under the care of a physician? YesNo

If yes, for what reason?
Have you been told you should be taking an antibiotic (premedication) prior to dental visits? YesNo

Are you taking a blood thinner (Coumadin)? YesNo

Are you presently taking any medications/drugs/pills? YesNo

If so, please list:
Are you presently taking a medication for soft bone (osteoporosis)(fosamax)? YesNo

(Women) Are you Pregnant? YesNo

If yes, how long?
Are you allergic to: PenicillinCodeineLocal AnestheticLatexNoneOther

List "other" allergies:
Pharmacy Name:
Pharmacy phone number:

Do you have, or have you ever had:

Heart Trouble: YesNo

Heart Murmur: YesNo

Heart Surgery: YesNo

Heart Pacemaker: YesNo

Rheumatic Fever: YesNo

High or Low Blood Pressure: YesNo

Ulcers: YesNo

Tuberculosis or Lung Disease: YesNo

Diabetes: YesNo

Epilepsy or Seizure Disorders: YesNo

Anemia: YesNo

Thyroid Problems: YesNo

Chemical Dependency: YesNo

Smoke/Chew or use any form of Tobacco: YesNo

Arthritis: YesNo

Excessive or Prolonged Bleeding: YesNo

Fainting Spells: YesNo

Jaundice: YesNo

Hepatitis: YesNo

If you have had Hepatitis, which type:
Asthma or Hay Fever: YesNo

Sinus Trouble: YesNo

Cancer: YesNo

Chemotherapy/Radiation: YesNo

Stroke: YesNo

Glaucoma: YesNo

Psychiatric Care: YesNo

Venereal Disease: YesNo

HIV Positive/Aids/ARC: YesNo

Prosthetic Implant/Joint Replacement: YesNo

Have you had any other serious illnesses, hospitalization or accident? YesNo

If yes, please explain:
Signature (type name):
Date:


Dental History

It is important to tell all dental personnel involved in your treatment about the general state of your health. This information is confidential.

Former Dentist:
Former Dentist Address:
When did you last visit a dentist?

X-rays Taken? YesNo

What was done at that time?
Why did you leave that practice:
Have you lost or have had any teeth removed, including wisdom teeth? YesNo

Why?
Do you have any bridge work or dentures? YesNo

Are you happy with the replacement? YesNo

Why?
Do you feel your breath is offensive at times? YesNo

Have you ever been told you have gum disease? YesNo

Have you ever had gum treatment or surgery? YesNo

Does food chronically collect between your teeth? YesNo

Are your Teeth acutely sensitive to: SweetColdHeatPressureNo

How often do you brush your teeth?
How often do you floss your teeth?
Do you clench or grind your teeth? YesNo

Does your jaw click or pop? YesNo

Do you have frequent headaches? YesNo

Have you had any orthodontic work? YesNo

Has any dental treatment been recommended to you that you have not done?
Are you happy with the appearance of your smile? YesNo

Explain:
Anything else that would be valuable for me to know? YesNo

Explain:
I certify that the above information is complete and accurate.
Patient's/Guardian's Signature (type name):
Date:

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