Please fill out the registration form to the best of your knowledge.
All patient information is confidential

 

Patient First Name: M.I.

Patient Last Name:

Patient Suffix : Patient Prefix:

Patient Nickname:

Sex: male female Date of Birth (MM/DD/YY) Please add slashes: Age:

Status: Married Divorced Legally Separated Widow Single Other

Social Security (no dashes):

Address 1:

Address 2:

City: State:

Zip: Province:

Country:

Home Tel (no dashes): Bus. Tel (no dashes): Ext.

Driver's License:

Patient Ethnicity (optional): Caucasian Black Hispanic Other

Emergency Contact:

Emergency Phone (no dashes):

Other Phone Description:

Other Phone 1 (no dashes):

Other Phone Description 2:

Other Phone 2 (no dashes):

Patient E-Mail (valid email is required):

Patient is Guarantor: Yes No

Dentist:

Orthodontist:

Physician:

Referred By:

Have you ever been a patient in our practice: Yes No

Method of Personal Payment: Cash Check Credit Card

A C C O U N T

 

Who will be responsible for your account? Self Spouse Father

Mother Other

Name:

Social Security:

Home Tel: Street:

City State: Zip

Employer: Tel:

I N S U R A N C E

 

Student: Full Time Part Time Not

School Name

School Address

Status: Married Divorced Legally Separated Widow Single

Employed: Full Time Part Time Retired Not

Do you belong to a PPO or HMO? Yes No

PRIMARY MEDICAL INSURANCE

 

Employer:

Address:

Bus. Tel:

Insurance Company Name:

Address:

Phone:

Group No.: Group Name:

Insured Party: Relation:

Sex: MF

Date of Birth (MM/DD/YY):

Street: City:

State: Zip

Phone: Social Security:

ID No.:

SECONDARY MEDICAL INSURANCE

 

Employer:

Address:

Bus. Tel:

Insurance Company Name:

Address:

Phone:

Group No.: Group Name:

Insured Party: Relation:

Sex: MF

Date of Birth (MM/DD/YY):

Street: City:

State: Zip

Phone: Social Security:

ID No.:

Please fill out the health history to the best of your knowledge

All patient information is confidential

Health problems that you may have or medication that you may be taking, could have an important interrelationship with the care that you will be receiving. Thank you for answering the following questions. Your answers are for our records only and will be considered confidential.

Reason for visit:

YES NO
Are you in good health:
Height: Weight:
Have there been any changes in your general health in the past year?
Are you under the care of a physician?
Date of last visit:
If so, for what are you being treated?
Have you had any illness, operation or been hospitalized in the past five years?
Do you have unhealed injuries or inflamed areas, growths or sore spots in or around your mouth?
If so describe where:
Do you have a prosthetic joint?
If so describe where:
Do you have a heart valve replacement or vascular graft?
If so describe where:

Have You Had or Do You
Currently Have		 Yes No Have You Had or Do You
Currently Have		 Yes No
Rheumatic fever? Stroke?
Damaged heart valves/
mitral valve prolapse?		 Thyroid trouble?
Heart murmur? Diabetes?
High blood pressure? Low blood sugar?
Low blood pressure? Kidney trouble?
Chest pain, angina? Are you on dialysis?
Heart attack(s)? Swollen ankles, arthritis
or joint disease?
Irregular heart beat? Stomach ulcers?
Cardiac pacemaker? Contagious diseases?
Heart surgery? Sexually transmitted diseases?
Bronchitis, chronic cough? Problems with the immune system?
Asthma? Delay in healing?
Hay fever / Sinus problems? A tumor or growth?
Tuberculosis? X-Ray treatment / chemotherapy?
Emphysema? Chronic fatigue / night sweats?
Difficult breathing
/ other lung trouble?		 Are you on a diet?
Do you smoke? A history of drug abuse?
Blood transfusion? A history of alcohol abuse?
Blood disorder such as anemia? Contact lenses?
Bruise easily? Eye disease / glaucoma?
Bleeding tendency
(abnormal bleed?)		 Mental health problems?
Jaundice, hepatitis or liver disease? A removable dental appliance?
Infectious mononucleosis? Pain & Clicking of jaws when eating?
Gallbladder trouble? Malignant Hyperthermia?
Fainting spells? If you are having surgery today, have you had anything to eat or drink in the last 8 hours?
Convulsions, epilepsy? Who is driving you home?

 

MEDICATION
Are You Now Taking... Yes No Yes No
Any kind of medicine, drugs, or pills? Have you ever taken diet pills?
Anticoagulants? Please list any other medications you are taking:
Tranquilizers?
Cortisone?
ALLERGIES
Are You Allergic To Or Had A Reaction To...
Yes
No
Are You Allergic To Or Had A Reaction To...
Yes
No
Local anesthetics? Codeine or other narcotics?
Penicillin? Other medications?
Other antibiotics? Latex?
Sodium pentothal, valium, or other tranquilizers? Please list any allergies other than drug allergies?
Aspirin?
WOMEN
Yes
No
Yes
No
Is there a possibility of pregnancy? Are you nursing?
Estimated delivery date? Are you taking birth control pills?
WOMEN NOTE: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician / gynecologist for assistance regarding additional methods of birth control.
Yes
No
Is there any condition concerning your health that the doctor should be told?
Do you wish to speak to the doctor privately about anything?
FAMILY HISTORY
Is there a family history of :
Yes
No
Is there a family history of :
Yes
No
Cancer Heart Disease
Diabetes Anesthetic Problems
IN CASE OF EMERGENCY, CONTACT:

Name:

Telephone #:

Work #:

INJURY
Yes
No
Yes
No
Is this visit related to an accident? Is this visit work related?
Other:
Date of Injury:

Insurance Company Handling The Claim:

Claim Number:

Name of Attorney / Adjustor:

Attorney / Adjustor Telephone #:

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