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Welcome to Jeff Gray, DDS - Sedation & Cosmetic Dentistry - General Information

Online Patient Registration Form

* indicates a required field
* Name: Married Single Minor
Male Female
* Address: *City:
# State: * Zip:
Birth Date: SSN:

Contact Numbers: (check where you would prefer we call or contact you.)

Home Phone: Home Email:
Work Phone: Work Email:
Cell Phone: Other Email:

Place of Employment or School?

Whom may we thank for referring you to our office?

Family Information

Father (or Husband)


First Name
M.
Last Name

Street

City
State
Zip

Home Phone
Work Phone

Birth Date
Social Security #

Mother (or Wife)


First Name
M.
Last Name

Street

City
State
Zip

Home Phone
Work Phone

Birth Date
Social Security #

IN CASE OF EMERGENCY

Outside of immediate household or family:


First Name
M.
Last Name

Street

City
State
Zip

Phone

Account & Payment

Person responisible for account:

To Be Provided In Office
Signature

Preferred Method of Payment

Cash or Check
Credit Card (Card Number and Exp. Date to be provided in office)
Alternative Billing Source (ask)

Dental History

Do you have a specific dental problem?

Describe: Yes No
Do you have regular dental care? Last Visit? Yes No
Do you think you have decay, gum disease or jaw problems? Yes No
Do you floss? How often? Yes No
Do your gums ever bleed? Yes No
Are you interested in improving your smile? Yes No
Would you like to have whiter teeth? Yes No
Does food catch between your teeth? Yes No
Do you have any loose teeth? Yes No
Do you ever have clicking, popping, or discomfort in your jaw joint? Yes No
Do you ever clench or grind your teeth? Yes No
Have you ever had a bad experience with a dentist? Yes No
Do you smoke or chew tobacco? Yes No
Name of previous dentist and location: (optional)
Last date of X-Rays: Bite Wings: Panorex: Full Series:

Symptoms: (Check all that apply)

Headaches Facial Pain
TMJ Pain Tender Sensitive Teeth
TMJ Noise Difficulty Chewing
Limited Opening Neck Pain
Ear Congestion Postural Problems
Dizziness Tingling In Fingers
Ringing In Ears Hot & Cold Sensitivity
Difficulty Swallowing Nervousness
Loose Teeth Insomnia
Clenching/Bruxing Trigeminal Neuralgia
Bells Palsy Back Pain

Medical History: (Check all that apply)

Heart Murmur Lung Disease Artificial Heart Valve Diabetes
Angina/Chest Pain Allergies Heart Pace Maker Kidney Disease
Heart Attack/Failure Sinus Problems Blood Disease Thyroid Disease
Congenital Heart Disorder Asthma Blood Pressure Problems Cold Sores
Mitral Valve Prolapse Snoring Bleed Easily Fever Blisters
Rheumatic Fever Liver Disease Hepatitis A, B, or C Cancer
Gaucoma HIV

Are you under a physicians care? Why?

Yes No
Are you taking any medications? What? Yes No
Are you allergic to any medications? What? Yes No
(Examples: Penicillin, Sulfa, Codeine, Latex, Metals, Acrylic)
Are you pregnant or trying? Contraceptives? Yes No
Have you had a serious accident or hospitalization? Yes No
Normal blood pressure if known?    
What is your favorite music or artist you enjoy listening to, when you relax?    

Visit Our Smile Gallery
FREE Sedation ($371 Value) when you register online or call today. (Includes medication and monitoring only, not any dental work)
*Name:
*Phone:
*Email
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Jeff Gray DDS | Sedation & Cosmetic Dentistry | 8555 Fletcher Parkway #102, La Mesa, CA  91942 | (619) 337-7700 | smile@smilesandiego.com