PATIENT REGISTRATION INFORMATION

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Responsible Party


Emergency Contact


Insurance Information

Primary Dental Insurance Company

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Primary Medical Insurance Company

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Health History

ft.
in.
lb.

Medications


Allergies/ Reactions


For Women Only

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


Have you had or do you currently have the following:


ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Click on the hyperlink to obtain a copy:

The Health Insurance Portability and Accountability Act of 1996 establishes an individual’s right to access and receive copies for their Protected Health Information (PHI). Additionally, this act provides for an individual to designate person(s) they are associated with, such as parent, guardian, spouse, child, etc. (this is in addition to their personal physician or dentist) to have access to their PHI. I hereby acknowledge that I have reviewed a copy of this office's Notice of Privacy Practices. I give my permission to discuss this account to the following:


Form Completion

I certify that I have read and understand the questions and answers to my medical history and that I will not hold my surgeon or any members of his staff responsible for any errors or omissions that I have made in the completion of this electronic record. I also understand that I am obligated to update this information whenever there are changes to my medical history including but not limited to diagnoses, medications, and allergies.

If Patient is a Minor

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