Patient Registration Form

Patient Name:

Date of Birth:

Phone Number:

Email Address:

Address:

Preferred Contact Method:

Emergency Contact Name:

Emergency Contact Phone Number:

How did you hear about Dental Zone?

Are you currently under the care of a physician?

List any medical conditions you have :

List any medications you are currently taking:

Are you allergic to any medications or materials (e.g., latex)?

Do you have any dental anxieties or fears?

Have you Undergone Dental Treatment Previously ?

Consent and Acknowledgement

I certify that the information provided on this form is complete and accurate to the best of my knowledge.