• Morgan Glaze, D.M.D.
    • Curtis Henderson, D.D.S.
    • 5895 Trinity Parkway, Suite 200
    • Centreville, VA 20120       703-818-1500
  • Patient Registration and Health History
  • Patient:
  • (First, M.I. Last)
  • Home Phone
  • Address
  • City
  • State
  • Zip
  • Sex:
  • M F
  • Birth date
  • Social Security #
  • E-Mail
  • Whom may we thank for referring you to our practice?
  • Doctor Referral Facebook Google Ad Insurance Referral Internet Search Personal Referral Other
  • Dental History
  • What is the reason for your visit today?
  • Date of Last Dental Visit
  • Last Dental Cleaning
  • Last Full Mouth X-Rays
  • How often do have dental examinations?
  • How often do you brush your teeth?
  • How often do you floss?
  • What other dental aids do you use? (Toothpick, mouth rinse, etc.)
  • Do you have any dental problems now?
  • YES NO
  • If yes, please describe
    • Are any of your teeth sensitive to:
    • Hot or Cold?
    • YES NO
    • Sweets?
    • YES NO
    • Biting or chewing
    • YES NO
    • Do your gums bleed or hurt?
    • YES NO
    • Do you have any loose teeth?
    • YES NO
    • Do you smoke/chew tobacco?
    • YES NO
    • Do you:
    • Notice mouth odors or bad tastes?
    • YES NO
    • Frequently get mouth sores?
    • YES NO
    • Mouth breathe?
    • YES NO
    • Have you experienced:
    • Clicking or popping of the jaw?
    • YES NO
    • Pain? (joint, ear, side of face)
    • YES NO
      • Have you ever had:
      • Orthodontic treatment?
      • YES NO
      • Oral Surgery?
      • YES NO
      • Gum treatment?
      • YES NO
      • Bite adjustments?
      • YES NO
      • Bite plate or splint?
      • YES NO
      • Serious mouth injury?
      • YES NO
    • Get food caught around teeth?
    • YES NO
    • Clench or grind your teeth?
    • YES NO
    • Have tired jaws?
    • YES NO
    • Difficulty in opening or closing?
    • YES NO
    • Difficulty in chewing?
    • YES NO
  • Do you feel nervous about having dental treatment?
  • YES NO
  • Have you ever had an upsetting dental experience?
  • YES NO
  • Overall, how would you evaluate your past dental treatment and experiences?
  • Excellent Good Fair Poor
  • Overall, how pleased are you with the appearance of your teeth and smile?
  • Extremely Pleased Moderately Pleased Satisfied Dissatisfied
  • Medical History
  • 1. Have you been under the care of a physician during the past two years?
  • YES NO
  • If yes, for what?
  • Physician's name
  • Phone
  • Address
  • City
  • State
  • Zip
  • 2. Are you taking any medication, including non-prescription, now?
  • If yes, for what?

  • 3. List any allergies to drugs or substances
  • 4. Indicate which of the following you have had, or have at present.
  • Yes No
    Heart (Surgery, Disease, Attack)
    Chest Pain
    Congenital Heart Disease
    Heart Murmur
    High Blood Pressure
    Mitral Valve Prolapse
    Artificial Heart Valve
    Rheumatic Fever
    Cortisone/Steroid Medicine
    Artificial Joints
    Hepatitis, Jaundice, Liver Disease
    Kidney Disease
  • Yes No
    Latex Sensitivity
    Sinus Problems
    Radiation Therapy
    Thyroid Problems
    Venereal Disease
    A.I.D.S. or HIV Infection
    Prolonged Bleeding
    Neurological disorders
    Epilepsy or Seizures
    Fainting or Dizzy Spells
    Psychiatric Care
    Chemical Dependency
  • 5. Do you have any disease, condition, or problem not listed?
  • If yes, please list
  • 6. Women:
  • Are you: Pregnant?
  • YES NO
  • Nursing?
  • YES NO
  • Taking birth control pills
  • YES NO
  • In case of any emergency, contact
  • Phone
  • Referred by
  • Dental Insurance
  • Employed by
  • Occupation
  • Business address
  • Business phone
  • Single Married Divorced Separated Widowed
  • Spouse Name
  • Spouse Employed By
  • Occupation
  • Business Address
  • Business phone
  • Person Responsible for Account (or Guardian)
  • Relationship
  • Dental Insurance Company
  • Insured's Name
  • Insured's SS#
  • Insured's Date of Birth
  • Please sign below for the assignment of insurance benefits.
  • Signature
  • Date
  • Financial Arrangements
  • Payment for services is due at the time services are rendered unless payment arrangements have been approved in advance. We accept cash, checks, and credit cards. We will be happy to help you process your insurance claim form. Returned checks and balances older than 30 days may be subject to additional collection fees and interest charges of 1 1/2% per month
  • We will gladly discuss your proposed treatment and answer any questions relating to your insurance. You must realize, however, that your insurance is a contract between you, your employer, and the insurance company. We are not a party to that contract. Our treatment recommendations are based upon achieving optimum dental health and not based upon what your insurance company allows.
  • While the filing of insurance claims is a courtesy that we extend to our patients, all charges are your responsibility from the date the services are rendered. We realize that temporary financial problems may affect timely payment of your account If such problems do arise, we encourage you to contact us promptly for assistance in the management of your account.
  • If you have any questions about the above information or any uncertainty regarding insurance coverage, PLEASE don't hesitate to ask us. We are here to help you.
  • Signature
  • Date
dental dental dental
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