New Patient Registration Form

For your convenience, we made our new patient registration forms online to save you time at your first appointment. Complete these forms and submit so we can refer to them on your visit.

If you have any questions, please give us a call at 760.726.4904.

Step 1 of 5 - Introduction

Welcome

We welcome you to our family of patients. Thank you for selecting us as your dental office. We want you to know that we pride ourselves on trying to make dentistry a pleasant experience. Our commitment is to provide you with the best dental treatment possible using state of the art techniques and materials.

Dr. Christopher Herman

Dr. Herman received his Doctor of Dental Surgery in 2006 from the University of the Pacific School of Dentistry in San Francisco, CA. He also earned a Bachelor of Science in Biology and Biomedical Sciences from CSU San Bernardino. Prior to attending dental school, Dr. Herman pursued a Master’s Degree in Public Health in Health Administration from Loma Linda University. He is an active member of the American Academy of Cosmetic Dentistry, the American Dental Association, California Dental Association, San Diego Dental Society. To stay on top of the latest advancements, Dr. Herman regularly attends continuing education courses learning the latest techniques in restorative, cosmetic, and minimally invasive dentistry. Dr. Herman is a native of Southern California and now lives in Carlsbad with his wife, two daughters, and his son.

Dr. Herman’s practice provides a friendly and warm atmosphere focusing on providing personalized care to his patients. His office is unique because of the strong focus on individualized care. This practice philosophy is why Dr. Herman’s office is highly rated and has been treating generations of families.

Our Staff

Our dental staff is made up of knowledgeable and highly qualified dental professionals representing over 30 years of experience. One of the reasons we can provide such competent and excellent care is that our entire staff is well trained in all aspects of dentistry. We take the time to thoroughly listen to your concerns and answer all your questions. We will customize your treatment to meet your individual needs.

We know this approach requires efficient teamwork and a long term commitment to excellence. We invite you to come in and experience it for yourself.

Patient Information

This information is important for our files and will be considered confidential.

Today's Date: January 17, 2025 at 4:36 am

Patient's Name(Required)

First Last

Date of Birth(Required)

Month

Day

Year

Age

Civil Status

Is patient a student?

Yes

Is patient a minor?

Yes

Name of School

City/State

Parent or Guardian's Name

First Last

Home Address(Required)

Street Address City ZIP / Postal Code

Home Phone #

Mobile Phone #(Required)

Email Address(Required)

Social Security #

Driver's License #

State

Patient/Parent/Guardian Employed By

Occupation

Workplace Address

Workplace Phone #

Spouse's Name

First Last

Spouse's Date of Birth

Month

Day

Year

Spouse's Social Security #

Spouse Employed By

Spouse's Occupation

Spouse's Workplace Address

Spouse's Workplace Phone #

Name of Nearest Relative NOT Living With You

First Last

Relationship

Relative's Address

Relative's Phone #

Name of Physician

First Last

Physician's City

Physician's Phone #

Name of Former Dentist

First Last

Former Dentist's City

Former Dentist's Phone #

Insurance Details

Primary Insured's Name

First Last

Secondary Insured's Name

First Last

Primary's Insurance Company

Secondary's Insurance Company

Primary's ID & Group Policy #

Secondary's ID & Group Policy #

Primary's Employer

Secondary's Employer

Insurance Information

If we have received all of your insurance information on the day of the appointment, we will be happy to file your claim for you. You must be familiar with your insurance benefits, as we will collect from you the estimated amount insurance is not expected to pay. By law your insurance company is required to pay each claim within 30 days of receipt. We file all insurance electronically, so your insurance company will receive each claim within days of the treatment. You are responsible for any balance on your account after 30 days, whether insurance has paid or not. If you have not paid your balance within 60 days a re-billing fee of 1.5% will be added to your account each month until paid. We will be glad to send a refund to you if your insurance pays us.

PLEASE UNDERSTAND that we file dental insurance as a courtesy to our patients. We do not have a contract with your insurance company, only you do. We are not responsible for how your insurance company handles its claims or for what benefits they pay on a claim. We can only assist you in estimating your portion of the cost of treatment. We at no time guarantee what your insurance will or will not do with each claim. We also can not be responsible for any errors in filing your insurance. Once again, we file claims as a courtesy to you.

Initial(Required)

Dental Appointment Cancellation/No Show Policy

Effective January 1, 2022, any established patient who fails to show or cancels/reschedules an appointment and has not contacted our office with at least 24 hours notice will be considered a No Show and charged a $50.00 fee.

We understand there may be times when an unforeseen emergency occurs and you may not be able to keep your scheduled appointment. If you should experience extenuating circumstances please contact our Office Manager, who may be able to waive the No Show fee. Should it be after regular business hours Monday through Thursday, or a weekend, you may leave a message via phone or text. Messages left at either location are acceptable.

Dr. Christopher Herman DDS
760.726.4904
chrishermandds@gmail.com

Initial(Required)

Terms and Conditions

As a condition of your treatment by this office financial arrangements must be made in advance. All emergency services or dental services performed without financial arrangements must be paid for at the time of visit. We will help prepare your insurance forms to assist in collection from your insurance and credit your account, however, this office cannot render services on the assumption that our charges will be paid by an insurance company. I grant you permission to telephone me at home or at work to discuss matters related to this form.

Acknowledgement

I have read and understand the above conditions.

Signature (Parent, if patient is a minor)(Required)

Health Questionnaire

Are you in good health?

Yes

Are you under the care of a physician?

Yes

Have you ever had any serious illness or operation?

Yes

If under the care of a physician, what is the condition being treated?

If you ever had any serious illness or operation, what was the illness or operation?

Have you ever been hospitalized?

Yes

Do you require antibiotic premedication for dental treatment?

Yes

If hospitalized, what was the reason?

If antibiotic premedication is require, which medication?

Do you have any disease or condition not listed that we should be aware of?

Yes

If yes, please explain

List of Medications You Are Currently Taking

Allergies or Sensitivities to

Aspirin

Penicillin

Codeine

Iodine

Latex

Barbiturates (sleeping pills)

Local Anesthetic

Tetracycline

Sulfa

Other

Artificial Joints

Hip

Knee

Other

Please list other allergies or sensitivities here

Hip Surgery Date

Knee Surgery Date

Specify Artificial Joint

Surgery Date

Do you have, or have you had, any of the following: (Please check known conditions)

Cardiac Conditions

Angina

Artificial Heart Valve

Congenital Heart

Lesions

Heart Murmur

Heart Problems

Mitral Valve Prolapse

Pacemaker

Rheumatic Fever

Scarlet Fever

Stroke

Diseases

AIDS

Blood Disease

Diabetes

Emphysema

Epilepsy

Glaucoma

Hepatitis

Herpes

HIV Positive

Jaundice

Kidney Disease

Liver Disease

Tuberculosis

Venereal Disease/STDs

Heart Murmur was diagnosed when?

Hepatitis Type

Other Conditions

Anemia

Arthritis/Rheumatism

Asthma

Back Problems

Bleeding Abnormally with Extraction, Surgery

Cancer

Chemical Dependency

Chemotherapy

Circulatory Problems

Contact Lenses

Cortisone Treatments

Cough, persistent or bloody

Fainting/Dizziness

Headaches

High Blood Pressure

Jaw Pain

Low Blood Pressure

Nervous Problems

Psychiatric Care

Radiation Treatment

Shortness of Breath

Sinus Trouble

Skin Rash

Special Diet

Swelling of Feet/Ankle

Thyroid Problems

Tonsillitis

Tumor/Growth on Head/Neck

Ulcer

Weight Loss

Cancer Type

Do you have a tobacco habit?

Yes

Current tobacco user?

Yes

Former tobacco user?

Yes

Have you ever taken Fen-Phen or Redux?

Yes

When have you taken Fen-Phen/Redux?

For how long have you taken Fen-Phen/Redux?

Are you on or have you ever taken oral bisphosphonate treatment such as Fosamax, Boniva or Actonel?

Yes

Have you ever taken Aredia or Zometa?

Yes

Have you ever had any unfavorable reaction from local anesthetic?

Yes

Have you had any serious trouble associated with previous dental treatment?

Yes

If yes, please explain

Have you ever had an upsetting experience in the dental office?

Yes

If yes, please explain

How long has it been since your last dental treatment?

How long has it been since your last x-rays?

How do you feel about your teeth?

Are you satisfied with the appearance of your teeth?

Does food tend to get caught between your teeth?

Yes

Do your gums often bleed when you brush?

Yes

Have you experienced problems with your jaw?

Yes

Do you grind or clench your teeth?

Yes

Do you have popping or soreness in your jaw?

Yes

Do you have difficulty opening or closing your mouth?

Yes

Do you have difficulty with chewing?

Yes

Have you ever had orthodontic treatment?

Yes

Have you ever had oral surgery?

Yes

Have you ever had periodontal treatment?

Yes

Have you ever worn a bite appliance?

Yes

When did you have orthodontic treatment?

When did you have oral surgery?

When did you have periodontal treatment?

For Women Only

Are you pregnant?

Yes

Are you nursing?

Yes

Are you taking birth control pills?

Yes

What month of pregnancy?

Certification

I hereby certify that the information on this Health Questionnaire is true and correct to the best of my knowledge.

Thank you for trusting your dental care to Dr. Herman’s Office. When you schedule an appointment with our office we set aside enough time to provide you with the highest quality care. Should you need to cancel or reschedule an appointment, please contact our office as soon as possible, and no later than 24 hours prior to your scheduled appointment. This gives us time to schedule other patients who may be waiting for an appointment.

This field is for validation purposes and should be left unchanged.

Prefer the print and fill out method? Click on the button below to download the form. Print and complete these forms and bring them to your visit.

DOWNLOAD NEW PATIENT INFORMATION FORM

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Awards

Testimonials

Dr. Herman and his staff are always professional, efficient, and friendly. They make sure you are comfortable and explain everything thoroughly. Worth the Drive from San Diego!

Stephanie Kennedy

My visit was the best treatment as I all receive when I come the your office. I’m very blessed to have found Dr. Herman and his staff, you’re the best.

Nick Mazzaro

I had a wonderful visit. The staff as always were cheerful and friendly. All my family regularly goes for all of our dental needs. We just love everyone there!

Jon Korona

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