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DR. CHRISTINE PHAN
DMD.
General & Implant Dentistry
New Patient Registration
1. Patient Information
First Name
Last Name
Date of Birth
Email Address
Phone Number
Mailing Address
2. Dental Insurance
Primary Dental Insurance Carrier (if any)
• We accept all major dental PPO insurance plans.
• For
Medi-Cal
and
Medicare Advantage
users, our front desk will contact you shortly with details.
3. Medical History & Lifestyle
Do you consider yourself to be in good health?
Select...
Yes
No
Fair
Approx. date of last dental visit?
Are you currently taking any medications? (Please list if yes)
Allergies (Check all that apply):
Penicillin
Latex
Codeine
Sulfa Drugs
Other:
Conditions (Check all that apply):
High Blood Pressure
Diabetes
Heart Disease
Asthma
Artificial Joints
Cancer
Submit to Office
