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Registration Form

 

Office Hours
For Dr. Peter A. Lakatos:
Tuesday: 8:00 a.m. - 12:00 p.m. & 2:00 p.m. - 5:00 p.m.
Wednesday: 8:00 a.m. - 12:00 p.m. & 2:00 p.m. - 5:00 p.m.
Thursday: 8:00 a.m. - 12:00 p.m. & 2:00 p.m. - 5:00 p.m.

For the Hygienist:
Tuesday: 8:00 a.m. - 12:00 p.m. & 1:00 p.m. - 5:00 p.m.
Wednesday: 8:00 a.m. - 12:00 p.m. & 1:00 p.m. - 5:00 p.m.
Thursday: 8:00 a.m. - 12:00 p.m. & 1:00 p.m. - 5:00 p.m.
 

Contact Us:
Total Patient Care Dentistry
Dr. Peter A. Lakatos, DMD
70 Allen Street
Rutland, VT  05701
(802) 773-1200
Fax: (802) 773-9467

Please complete the following form and click Submit. One of our team members will be contacting you as soon as possible in order to schedule a convenient time for your first appointment.

1. About You
Today's Date:
 E-mail Address *
First Name *
 Last Name *
I prefer to be called:
 Gender
Birthdate:
Age:
 SS #:
Street Address
City
 State
 		Zip Code

Single    Married    Divorced    Widowed    Separated   
Hm #:
 Pager / Other #:
Wk #:
 Ext:
 DL #:
Employer:
Employers Address:
How long there?:
 Occupation:
When and where are the best times to reach you?
Whom may we thank for referring you?:
Other family members seen by us:
Previous / Present Dentist:
Last Visit Date:
2. Spouse Information
His / Her Name
Employer:
Wk #:
 Ext:
 SS #:
Birthdate:
 Driver's License #:
Person responsible for account:
Wk #:
 Ext:
 Hm #:
Billing Address:
Relation:
 SS #:
Employer:
 DL #:

3. Insurance Coverage
Primary
Dental Coverage
 		Medical Coverage:
Insurance Co. Name
Insurance Co. Address:
Insurance Co. Phone #:
 Group # (Plan, Local or Policy #):
Insured's Name:
 Relation:
Insured's Birthdate:
 Insured's SS #:
Insured's Employer:
Secondary
Dental Coverage:
 		Medical Coverage:
Insurance Co. Name:
Insurance Co. Address:
Insurance Co. Phone #:
 Group # (Plan, Local or Policy #):
Insured's Name
 Relation:
Insured's Birthdate:
 Insured's SS #:
Insured's Employer:
In the event of an emergency, is there someone who lives near you that we should contact?
His / Her Name:
 Relation
Wk #:
 Hm #:
4. Medical History
Do you have a personal physician?
Physician's Name:
Phone #:
 Date of last visit:
Your current physical health is:
Are you currently under the care of a physician?:
Please explain:
Are you taking any prescription / over the counter drugs?:
Please list each one:
Do you smoke or use tabacco in any other form?:
For Women: Are you taking birth control pills?
Are you pregnant?
 		Week #:
Are you nursing?
Have you ever had any of the following diseases or medical problems? (check all that apply)
Abnormal Bleeding    Alcohol / Drug Abuse    Anemia   
Arthritis    Artificial Bones / Joints / Valves    Asthma   
Blood Transfusion    Cancer / Chemotherapy    Colitis   
Congenital Heart Defect    Diabetes    Difficulty Breathing   
Emphysema    Epilepsy    Fainting Spells   
Frequent Headaches    Glaucoma    Hay Fever   
Heart Attack    Heart Murmur    Heart Surgery   
Hemophilia    Hepatitis    Herpes / Fever Blisters   
High Blood Pressure    HIV+ / AIDS    Hospitalized For Any Reason   
Kidney Problems    Liver Disease    Low Blood Pressure   
Mitral Valve Prolapse    Pacemaker    Psychiatric Problems   
Radiation Treatment    Rheumatic / Scarlet Fever    Seizures   
Shingles    Sickle Cell Disease / Traits    Sinus Problems   
Stroke    Thyroid Problems    Tuberculosis (TB)   
Ulcers    Venereal Disease   
Please list any serious medical condition(s) that you have ever had:
Are you allergic to any of the following? (check all that apply)
Aspirin    Codeine    Dental Anesthetics   
Erythromycin    Jewelry    Latex   
Metals    Penicillin    Tetracycline   
Please list any other drugs / materials that you are allergic to:
5. Dental History
Why have you come to the dentist today?
Do you require antibiotics before dental treatment?
Are you currently in pain?
Have you ever had a serious / difficult problem associated with any previous dental work?
Do you now or have you ever experienced pain / discomfort in your jaw joint (TMJ / TMD)?
Your current dental health is
Do you like your smile?
Would you like whiter teeth?
 		Fresher Breath?
Do your gums ever bleed?
How many times a week do you floss?
 a day do you brush?
Type of bristles?

* Required to submit this form




Peter A. Lakatos, DMD; 70 Allen Street; Rutland, VT 05701
(802)773-1200 Fax(802)773-9467

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