Bush Patient Registration

PATIENT REGISTRATION INFORMATION

Patient First Name

Middle Initial

Patient Last Name

Patient Nickname

Gender

Male Female

Date of Birth

Age

SSN

Driver's License #

Email

Address

City

State

Zipcode

Home Phone

Cell Phone

Marital Status

Employer

Occupation

Business Phone

Who can we thank for referring you to our practice?

Other

Referral Name

Who will be responsible for your account?

Other

Responsible Person First Name

Responsible Person Last Name

SSN

Date of Birth

Age

Telephone

Address

City

State

Zipcode

Employer

Business Phone

Insurance Information

Primary Dental Insurance Company

Primary Policy Holder

Primary Policy Holder

Relation

Gender

Male Female

SSN

Date of Birth

Address

City

State

Zip Code

Telephone

Primary Policy Holder Employer

Business Address

City

State

Zip Code

Business Telephone

Insurance Company Name

Insurance Company Address

City

State

Zip Code

Telephone

Policy I.D. #

Group #

Plan Name

Secondary Dental Insurance Company

Do you have secondary dental insurance?

Yes No

Secondary Policy Holder

Secondary Policy Holder

Relation

Gender

Male Female

SSN

Date of Birth

Address

City

State

Zip Code

Telephone

Secondary Policy Holder Employer

Business Address

City

State

Zip Code

Business Telephone

Insurance Company Name

Insurance Company Address

City

State

Zip Code

Telephone

Policy I.D. #

Group #

Plan Name

Health History

Are you under the care of a physician?

Yes No

Date of last visit?

Physician Name

Physician Phone

Preferred Pharmacy

Pharmacy Location

Pharmacy Phone

Do you smoke or use tobacco

Yes No

Have you had or do you currently have the following:

Abnormal Bleeding

Yes No

AIDS/HIV

Yes No

Alcohol Abuse

Yes No

Anemia

Yes No

Arthritis

Yes No

Artificial Heart Valve

Yes No

Artificial Joints

Yes No

Asthma

Yes No

Blood Disease

Yes No

Blood Transfusion

Yes No

Cancer

Yes No

Chemotherapy?

Yes No

Chest Pains

Yes No

Cold Sores/Fever Blisters

Yes No

Congenital Heart Defect

Yes No

Diabetes?

Yes No

Drug Abuse?

Yes No

Emphysema?

Yes No

Epilepsy

Yes No

Fainting Spells/Dizziness

Yes No

Frequent cough?

Yes No

Frequent Headaches

Yes No

Glaucoma?

Yes No

Heart Attack/Failure

Yes No

Heart Disease

Yes No

Heart murmur?

Yes No

Heart surgery?

Yes No

Hemophilia

Yes No

Hepatitis A

Yes No

Hepatitis B

Yes No

Hepatitis C

Yes No

High blood pressure?

Yes No

Irregular heart beat?

Yes No

Jaundice?

Yes No

Jaw Joint Pain

Yes No

Kidney Problems

Yes No

Liver disease?

Yes No

Low blood pressure?

Yes No

Mitral valve prolapse?

Yes No

Osteoporosis

Yes No

Pacemaker

Yes No

Psychiatric Care

Yes No

Radiation Therapy

Yes No

Respiratory Problems

Yes No

Rheumatic fever

Yes No

Rheumatism

Yes No

Seizures

Yes No

Shingles

Yes No

Sickle Cell Disease

Yes No

Sinus Problems

Yes No

Sleep Apnea

Yes No

Stomach/Intestinal Problems

Yes No

Stroke?

Yes No

Thyroid Problems

Yes No

Tuberculosis?

Yes No

Tumors/Growths

Yes No

Ulcers

Yes No

Venereal Disease

Yes No

Is there any disease, condition, or problem that you think our office should know about that is not listed above?

Yes No

Please list below

Medications

Please list all medications, that you are currently taking (include medication name, dosage and frequency):

Allergies/ Reactions

Are you allergic to, or had a reaction to any of the following:

Aspirin?

Yes No

Codeine?

Yes No

Dental Anesthetic

Yes No

Erythromycin

Yes No

Jewelry

Yes No

Latex

Yes No

Metals

Yes No

Penicillin

Yes No

Sulfa drugs?

Yes No

Tetracycline

Yes No

Allergy/Reactions not listed above

Yes No

Please list medication allergies

Additional Notes/Comments

For Women Only

Is there a possibility of pregnancy?

Yes No

If yes, number of weeks

Are you nursing?

Yes No

Are you taking birth control pills?

Yes No

WARNING: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician for assistance regarding additional methods of birth control.

Form Completion

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's health. It is my responsibility to inform the dental office of any changes in medical status

If Patient is a Minor

Form signed by:

Relationship to Patient:

Date

Authorization

Signature of Patient or Guardian

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