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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