Patient Registration form and medical history costa

Alternative text

PATIENT REGISTRATION INFORMATION

Patient First Name

Middle Initial

Patient Last Name

Patient is:

Policy Holder Responsible Party

Patient Nickname

Date of Birth

Age

Social Security #

We use your Social Security # to verify your insurance

Driver's License #

Address

City

State

Zipcode

Home Phone

Work Phone

Ext:

Cell Phone

Email

Gender

Male Female

Marital Status

Responsible Party

Responsible Person First Name

Responsible Person Last Name

Middle Initial

Address

City

State

Zipcode

Telephone

Business Phone

Ext

Cell Phone

Date of Birth

Social Security #

Driver's License #

Email

Responsible Party is also a Policy holder for Patient Primary Insurance Policy Holder Secondary Insurance Policy Holder

Do you have insurance?

Yes No

Primary Insurance Company

Relationship to Insured

Self Spouse Child Other

Primary Policy Holder

Primary Policy Holder

Social Security #

We use your Social Security # to verify your insurance

Date of Birth

Primary Policy Holder Employer

Insurance Company Name

Insurance Company Address

City

State

Zip Code

Group #

Subscriber ID#

Who can we thank for referring you to our office?

Signage New Resident Gift Yelp

Google Social Media Insurance

Print Ad Mailer/Postcard Community Event

Print Ad

Mailer/Postcard

Community Event

Current Patient Referring Doctor Website: Little Smiles

Current Patient

Referring Doctor

Website: Costa Family & Cosmetic Dentistry

Health History

Have you ever been hospitalized or had a major operation?

Yes No

Please describe

Are you under the care of a physician?

Yes No

Date of last visit?

Have you ever had a serious head or neck injury?

Yes No

Please describe

Are you taking any medications pills or drugs?

Yes No

Please describe

Have you ever taken Fosemex, Boniva, Actonel or any other medications containing bisphosphonates?

Yes No

Please describe

Are you on a special diet

Yes No

Please describe

Do you use tobacco?

Yes No

Have you had or do you currently have the following:

AIDS/IAN Positive

Yes No

Alzheimer’s Disease

Yes No

Anaphlaxis

Yes No

Anemia

Yes No

Angina

Yes No

Artificial Heart Valve

Yes No

Artificial Joint

Yes No

Arthritis/Gout

Yes No

Asthma

Yes No

Blood Disease

Yes No

Blood Transfusion

Yes No

Breathing Problems

Yes No

Bruise Easily

Yes No

Cancer

Yes No

Chemotherapy

Yes No

Chest Pains

Yes No

Cold Sores/Fever Blisters

Yes No

Congenital Heart Disorder

Yes No

Convulsions

Yes No

Cortisone Medicine

Yes No

Diabetes

Yes No

Drug Addiction

Yes No

Easily Winded

Yes No

Emphysema

Yes No

Epilepsy or Seizures

Yes No

Excessive Bleeding

Yes No

Excessive Thirst

Yes No

Fainting Spells/Dizziness

Yes No

Frequent Cough

Yes No

Frequent Diarrhea

Yes No

Frequent Headaches

Yes No

Genital Herpes

Yes No

Glaucoma

Yes No

Hay Fever

Yes No

Heart Attack/Failure

Yes No

Heart Murmur

Yes No

Heart Pacemaker

Yes No

Heart Trouble/Disease

Yes No

Hemophilia

Yes No

Hepatitis A

Yes No

Hepatitis B or C

Yes No

Herpes

Yes No

High blood pressure

Yes No

High Cholesterol

Yes No

Hives or Rash

Yes No

Hypoglycemia

Yes No

Irregular Heartbeat

Yes No

Kidney Problems

Yes No

Leukemia

Yes No

Liver Disease

Yes No

Low blood pressure

Yes No

Lung Disease

Yes No

Mitral Valve Prolapse

Yes No

Osteoporosis

Yes No

Pain in Jaw Joints

Yes No

Parathyroid Disease

Yes No

Psychiatric Care

Yes No

Radiation Treatments

Yes No

Recent Weight Loss

Yes No

Renal Dialysis

Yes No

Rheumatic fever

Yes No

Rheumatism

Yes No

Scarlet Fever

Yes No

Shingles

Yes No

Sickle Cell Disease

Yes No

Sinus Trouble

Yes No

Sleep Apnea

Yes No

Spina Bifida

Yes No

Stomach/Intestinal Disease

Yes No

Stroke

Yes No

Swelling of Limbs

Yes No

Thyroid Disease

Yes No

Tonsilitis

Yes No

Tuberculosis

Yes No

Tumor or Growths

Yes No

Ulcers

Yes No

Venereal Disease

Yes No

Yellow Jaundice

Yes No

Allergies/ Reactions

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

Aspirin?

Yes No

Sulfa drugs?

Yes No

Metal

Yes No

Local Anesthetic

Yes No

Acrylic

Yes No

Penicillin?

Yes No

Other Medications?

Yes No

Please list medication allergies

Codeine?

Yes No

Latex?

Yes No

Any Non-Medication Allergy?

Yes No

Please list non-medication allergies

Other Health Related Questions

Have you ever had any serious illness not listed?

Yes No

Please describe

For Women Only

Is there a possibility of pregnancy?

Yes No

Are you nursing?

Yes No

Taking oral contraceptives?

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.

Authorization

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.

Signature of Patient, Parent or Guardian:

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Date

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