Patient Registration

PATIENT REGISTRATION INFORMATION

Mr. Mrs. Ms. Dr.

Patient First Name

Middle Initial

Patient Last Name

Gender

Male Female

Date of Birth

Age

Social Security #

Please enter without spaces or dashes

Address

City

State

Zip Code

Email

Home Phone

Cell Phone

Marital Status

Employment Status

Full Time Part Time Retired Not Employed

Employer

Business Telephone

Address

City

State

Zip Code

Student Status

Full Time Part Time Not a Student

School Name

Address

City

State

Zip Code

Referring Provider First Name

Referring Provider Last Name

Address

City

State

Zip Code

General Dentist First Name

General Dentist Last Name

Address

City

State

Zip Code

Responsible Party

Who will be responsible for your account

Relationship to Patient

First Name

Last Name

Date of Birth

Address

City

State

Zip Code

Email

Home Phone

Cell Phone

Emergency Contact

First Name

Last Name

Primary Telephone

Relationship to Patient

Insurance Information

Do you have dental insurance?

Yes No

Are you the Primary Policy Holder?

Yes No

Primary Dental Insurance Company

Primary Policy Holder First Name

Primary Policy Holder Last Name

Relation

Gender

Male Female

Social Security #

Please enter without spaces or dashes

Date of Birth

Address

City

State

Zip Code

Telephone

Primary Policy Holder Employer

Insurance Company Name

Insurance Company Address

City

State

Zip Code

Telephone

Group #

Policy I.D. #

Please enter without spaces or dashes

Do you have medical insurance?

Yes No

Are you the Primary Policy Holder?

Yes No

Primary Medical Insurance Company

Medical Policy Holder First Name

Medical Policy Holder Last Name

Relation

Gender

Male Female

Social Security #

Please enter without spaces or dashes

Date of Birth

Address

City

State

Zip Code

Telephone

Policy Holder Employer

Insurance Company Name

Insurance Company Address

City

State

Zip Code

Telephone

Group #

Policy I.D. #

Please enter without spaces or dashes

Health History

Height

ft.

in.

Weight

lb.

Have you had any illness, operation or been hospitalized in the past five years?

Yes No

If yes, please describe

Is there any condition concerning your health or your family’s anesthetic history that the doctor should be told?

Yes No

If yes, please describe

Do you have a prosthetic joint or valve?

Yes No

Do you smoke, chew tobacco or vape?

Yes No

Per day?

Per week?

Do you use alcohol?

Yes No

Per day?

Per week?

Medications

Are you currently taking any medications?

Yes No

Please list all medications, drugs, pills, or herbs you are currently taking.

Allergies/ Reactions

Do you have any medication, food, and/or any environmental allergies?

Yes No

Please list all allergies including Penicillin, Aspirin, eggs or egg products.

For Women Only

Are you pregnant or trying to become pregnant?

Yes No

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.

Have you had or do you currently have the following:

Prosthetic Heart Valve

Yes No

Congenital Heart Disease

Yes No

Previous Endocarditis

Yes No

High Blood Pressure

Yes No

Cardiac Transplant

Yes No

Chest Pain, Angina

Yes No

Heart Attack

Yes No

Irregular Heart Beat

Yes No

Cardiac Pacemaker

Yes No

Heart Surgery

Yes No

Bronchitis, Chronic Cough

Yes No

Asthma

Yes No

Hayfever, Sinus Problems

Yes No

Tuberculosis

Yes No

Emphysema

Yes No

Difficulty Breathing

Yes No

Blood Transfusion

Yes No

Blood Disorder (Anemia)

Yes No

Bruise Easily

Yes No

Abnormal Bleeding Tendency

Yes No

Jaundice, Hepatitis, Liver Disease

Yes No

Infectious Mononucleosis

Yes No

Stroke

Yes No

Thyroid Trouble

Yes No

Diabetes

Yes No

Low Blood Sugar

Yes No

Kidney Trouble

Yes No

Are you on Dialysis

Yes No

Swollen Ankles, Arthritis, Joint Disease

Yes No

Stomach Ulcers

Yes No

Contagious Disease

Yes No

Sexually Transmitted Disease

Yes No

Problems of the Immune System

Yes No

Tumor or Growth

Yes No

Mental Health Problems

Yes No

Removable Dental Appliance

Yes No

Are you on a diet

Yes No

Are you taking bisphosphonates (Fosamax)

Yes No

Contact Lenses

Yes No

Eye Disease, Glaucoma

Yes No

Radiation Treatment, Chemotherapy

Yes No

Pain and Clicking of the Jaws

Yes No

Malignant Hyperthermia

Yes No

Convulsions, Epilepsy

Yes No

Please explain any YES answers or other medical problems not mentioned.

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Click on the hyperlink to obtain a copy:

Mclean & Capitol Oral, Facial & Implant Surgery Notice of Privacy Practices

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:

Name of Designated Person

Relationship to Patient

Name of Designated Person

Relationship to Patient

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.

Patient Signature (Parent or Guardian if minor):

Clear

Clear

Date

If Patient is a Minor

Form signed by

Relationship to Patient