Portside Dentistry
351 Hospital Rd, Suite 201
Newport Beach, CA 92663
T: 949-646-7707 F: 949-646-7795
PATIENT REGISTRATION
PATIENT INFORMATION
Today’s Date:____________
Patient Name: First_______________MI____Last____________________Nickname_____________
Home Address: Street_________________________City_____________________State________
Zip ____________E-mail address:__________________________________________________
Phone: Home_______________________ Mobile_________________________________
Social Security Number:______________________Date of Birth:_______________________
Driver’s License #:________________State:_____________________________
Patient Employed By: ____________Occupation:___________Phone:_________
Address: Street _________________City_________________State________Zip_____________
Sex: Male Female
Marital Status:  MinorMarried Single Divorced Separated Widowed
In case of emergency, who should be notified? _________________________________________
Relationship to Patient:___________________Home Phone:_____________Mobile:____________
How did you hear about our practice?_________________________________________________
ACCOUNT INFORMATION
Person Responsible for Account
Name: First ______________________Last___________________________
Relationship to Patient: Self Spouse Parent Other _____
If other than patient:
Date of Birth: _____________
Address: Street___________City ____________State _____Zip ____________
Phone: Home ____________Mobile ______________________
Employer:_______________Occupation______Work Phone ________________
Work Address: Street___________________City__________________State___Zip___________
DENTAL INSURANCE INFORMATION
Primary Insurance Co.: ________________Group #:_____________Subscriber SS #:_________
Name of Subscriber:____________________Subscriber Date of Birth:_________________
Patient Relationship to Subscriber:__________
Secondary Insurance Co.: ______________Group #: _____________Subscriber SS #:_________
Name of Subscriber:_____________________Subscriber Date of Birth:________________
Patient Relationship to Subscriber:__________
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Portside Dentistry
351 Hospital Rd, Suite 201
Newport Beach, CA 92663
T: 949-646-7707 F: 949-646-7795
HEALTH INFORMATION
Patient Name: First _________________MI ____ Last __________________Date of Birth _________
Circle appropriate answer:
Yes/ No Are you under the care of a physician for anything other than routine care?
If YES, explain __________________________________________________________
Date of last exam? __________ Reason for exam _______________________________
Name of Primary Care Physician__________Phone #:_________Address:___________
Yes/ No Are you allergic to any drugs or medications?
If YES, explain __________________________________________________________
Yes/ No Are you taking any medications, including herbal supplements?
If YES, explain __________________________________________________________
Yes/ No Have you ever been admitted to a hospital or required emergency care?
If YES, explain __________________________________________________________
Yes/ No Are you in pain now?
If YES, explain __________________________________________________________
Yes/ No Have you ever been pre-medicated for dental treatment?
If YES, why? ___________________________________________________________
Yes/ No Do you smoke or chew tobacco?
Women only:
Yes/No Do you suspect or are you pregnant?
If YES, how many months?________
Yes/No Are you taking birth control pills?
Yes/No Are you nursing?
Have you had or do you have any of the following? (Please circle all that apply)
Heart murmur/Mitral valve prolapse
Psychiatric or psychological care
Gastrointestinal disease
Rheumatic fever
Congenital heart disease
Neurological disorders
Glaucoma
Heart surgery, disease, attack
Pacemaker
Nervousness or anxiety
Hepatitis
Stroke
Fainting/dizzy spells
Kidney disease
Artificial heart valve
Epilepsy/seizures
Liver disease/jaundice
Chemotherapy/radiation
Hip or knee joint replacement
Asthma/TB/lung disease/Emphysema Blood disease/anemia
Bisphosphonate drug treatments
Venereal disease
Thyroid disease
Tumors, growths, cancer
HIV/AIDS
Arthritis/rheumatism
High or low blood pressure
Drug or alcohol dependency
Diabetes
Use this space or write on back for any additional information or explanations:_________________
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Portside Dentistry
351 Hospital Rd, Suite 201
Newport Beach, CA 92663
T: 949-646-7707 F: 949-646-7795
DENTAL HEALTH INFORMATION
What is the reason for your visit today? _________________________________________________
Last dental visit:_____________ Last dental cleaning:_________________ Last x-rays:__________
What was done at your last dental visit? _________________________________________________
Previous Dentist: Name:______________________________________________________________
Address:__________________ State:______Zip: _________Telephone:________
How often do you brush your teeth?___________ How often do you floss? ____________________
Do you have any dental problems now? Yes/ No
If YES, please describe______________________________
Have you had or do you have any of the
following?
Hot or cold sensitivity
Yes No
Sweets sensitivity
Yes No
Biting or chewing sensitivity
Bad breath/bad taste
Cold sores/blisters/oral lesions
Bleeding or painful gums
Loose teeth or change in bite
Catching food in between teeth
Discolored teeth
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Use tobacco in any form?
Yes No
Have your parents experienced gum disease or tooth loss?
Yes No
Are you satisfied with your teeth’s appearance? 
Yes No
If not, please explain:____________________
Was your previous dental experience favorable?
If not, please explain:_____________________
Is there anything else about having dental treatment that
you would like to discuss with the dentist?
Yes No
If yes, please describe:_________
Have you ever had?
Orthodontic treatment
Yes No
Oral surgery
Yes No
Periodontal treatment
Yes No
Teeth or bite adjusted
Yes No
Mouth Guard
Yes No
Serious injury to mouth or head? Yes No
If yes, please explain:__________________
Have you had or do you have any of the
following?
Clicking or popping of the jaw
Yes No
Pain (joint, ear, teeth, face)
Yes No
Difficulty opening/ closing mouth Yes No
Head/neck/shoulder aches
Yes No
Clenching/grinding of teeth
Yes No
Bite your lips or cheeks
Yes No
Hold foreign objects with teeth
Yes No
(Pencils, pipe, fingernails)
Mouth breathe
Yes No
Tired jaws, especially in morning Yes No
Snoring/sleeping disorder
Yes No
I have answered the aforementioned health questions to the very best of my knowledge. I will advise Dr. Ming
Truong or the dental staff of any changes in my health history. I give this dental office consent to release my health
information and x-rays relevant to my treatment to my insurance carriers, physicians or dental specialists that I may
be referred to.
Signature______________________________________Date____________________________
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Portside Dentistry
351 Hospital Rd, Suite 201
Newport Beach, CA 92663
T: 949-646-7707 F: 949-646-7795
OFFICE POLICIES
We are committed to providing you with the best possible care and helping you achieve your optimum oral health.
Toward these goals, we would like to explain your financial and scheduling responsibilities with our practice.
PAYMENT POLICY: Please be prepared for any deductible, co-pay, or other expenses at the time of service.
Financial arrangements are discussed during the initial visit and a financial agreement is completed in advance of
performing any treatment with our practice. For your convenience, we accept the following forms of payment: cash,
check, credit cards, and zero to low interest third-party financing through CareCredit.
DENTAL INSURANCE: Your dental benefit is a contract between you or your employer and the dental benefit plan.
Benefits and payments received are based on the terms of the contract negotiated between you or your employer
and the plan. We are happy to help our patients with dental benefit plans to understand and maximize their coverage.
As a courtesy, we will file your dental insurance claim for you and accept assignment of payment. Some insurance
companies recommend a pre-treatment authorization for the dental treatment to be provided. We will attempt to
estimate any expenses prior to your visit to our office.
If our estimate of your portion is less than the amount determined by your plan, the amount billed to you will be
adjusted to reflect this.
APPOINTMENTS & CANCELLATION POLICY: We reserve an appointment on the schedule for each patient
procedure and are diligent about being on-time. Because of this courtesy, when a patient cancels an appointment, it
impacts the overall quality of service we are able to provide. To maintain the utmost service and care, we request
a 24-hour notice to reschedule an appointment. If you do not show up to a scheduled appointment, there will
be a fee of $50 and a deposit to reserve the appointment time again, may be required. To serve all of our
patients in a timely manner, we may need to reschedule an appointment if a patient is fifteen minutes late or more
arriving to our practice. To reschedule an appointment due to late arrival, a fee of $50 or deposit to reserve the
appointment time again, may be required.
E-MAIL COMMUNICATION: Our office uses email for non-urgent communication with our patients including
appointment reminders. There is some risk that any individually identifiable health information and other sensitive or
confidential information that may be contained in such email may be misdirected, disclosed to or intercepted by,
unauthorized third parties. We will use the minimum necessary amount of protected health information in any
communication.
Authorizations:
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
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I understand that the information I have given today is correct to the best of my knowledge. ___(initial)
I have read the above and agree to the financial and scheduling terms. ___(initial)
I authorize the release of information necessary to process my dental benefit claims. I hereby authorize
payment directly to Dr. Ming Truong for dental services otherwise payable to me. ____(initial)
I hereby acknowledge that a copy of this practice’s Notice of Privacy Practices has been made available to
me. (separate enclosure) I have been given the opportunity to ask any questions I may have regarding this
Notice. ___(initial)
I hereby acknowledge that a copy of this practice’s Dental Materials Fact Sheet has been made available to
me. (separate enclosure) I have been given the opportunity to ask any questions I may have regarding this
Fact Sheet.___(initial)
Patient Signature________________________________________________Date______________________
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