Perry Hall 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

Extension

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

Do you have dental insurance?

Yes No

Primary Dental Insurance Company

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

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

Height

Weight

Are you under the care of a physician?

Yes No

Date of last visit?

Physician Name

Physician Phone

Preferred Pharmacy

Pharmacy Location

Pharmacy Phone

Have you been abused?

Yes No

Are you being abused now?

Yes No

If yes, do you need help?

Yes No

Do you smoke or use tobacco

Yes No

Have you had or do you currently have the following:

Pre-Med-Amox

Yes No

Pre-Med-Clind

Yes No

Pre-Med-Other

Yes No

Abnormal Bleeding

Yes No

AIDS/HIV

Yes No

Alcohol Abuse

Yes No

Allergies

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

Diabetes

Yes No

Drug Abuse

Yes No

Epilepsy

Yes No

Emphysema

Yes No

Fainting

Yes No

Fever Blisters

Yes No

Frequent Headaches

Yes No

Glaucoma

Yes No

Head Injuries

Yes No

Heart Attack/Failure

Yes No

Heart Disease

Yes No

Heart Murmur

Yes No

Heart Defect

Yes No

Hepatitis A

Yes No

Hepatitis B

Yes No

Hepatitis C

Yes No

High Blood Pressure

Yes No

Jaundice

Yes No

Jaw Joint Pain

Yes No

Kidney Disease

Yes No

Liver Disease

Yes No

Low Blood Pressure

Yes No

Mitral Valve Prolapse

Yes No

Pacemaker

Yes No

Psychiatric Care

Yes No

Radiation Treatment

Yes No

Respiratory Problems

Yes No

Rheumatic fever

Yes No

Rheumatism

Yes No

Seizures

Yes No

Sickle Cell Disease

Yes No

Sinus Problems

Yes No

Sleep Apnea

Yes No

Stomach/Intestinal Problems

Yes No

Stroke

Yes No

Tobacco Use

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.

Fees & Payments

I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment. I hereby authorize the Dental Office to administer such medications and perform such diagnostic, photographic, and therapeutic procedures as may be necessary for proper dental care. The information on this page and the dental/medical histories are correct to the
best of my knowledge. I grant the right to the dentist to release my dental/medical histories and other information about my dental treatment to third party payors and/or other health professionals.

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

Clear

Clear

PATIENT REGISTRATION INFORMATION

Who will be responsible for your account?

Insurance Information

Primary Dental Insurance Company

Secondary Dental Insurance Company

Health History

Have you had or do you currently have the following:

Medications

Allergies/ Reactions

For Women Only

Fees & Payments

Form Completion

If Patient is a Minor

Authorization

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