Pt Reg

PATIENT REGISTRATION INFORMATION

Patient First Name

Middle Initial

Patient Last Name

Patient Nickname

Gender

Male Female

Date of Birth

Age

Social Security #

Driver's License #

Email

Address

City

State

Zip Code

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

Zip Code

Employer

Business Phone

Insurance Information

Do you have dental insurance?

Yes No

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

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 had any recent surgeries?

Yes No

If yes, please describe

Have you had or do you currently have the following:

Abnormal Bleeding

Yes No

Allergies

Yes No

Alcohol Abuse

Yes No

Anemia

Yes No

Angina Pectoris

Yes No

Arthritis

Yes No

Artificial Heart

Yes No

Artificial Bones

Yes No

Asthma

Yes No

Blood Disease

Yes No

Blood Transfusion

Yes No

Cancer-Chemotherapy

Yes No

Colitis

Yes No

Congenital Heart

Yes No

Cosmetic Surgery

Yes No

Diabetes

Yes No

Difficulty Breathing

Yes No

Drug Abuse

Yes No

Emphysema

Yes No

Epilepsy

Yes No

Fainting Spells

Yes No

Fever Blisters

Yes No

Frequent Headaches

Yes No

Glaucoma

Yes No

Hay Fever

Yes No

Heart Attack

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

HIV+ / AIDS

Yes No

Irregular Heart Beat

Yes No

Jaundice

Yes No

Jaw Joint Pain

Yes No

Joint Replacements

Yes No

Kidney Disease

Yes No

Liver Disease

Yes No

Low Blood Pressure

Yes No

Mitral Valve Prolapse

Yes No

Osteoporosis

Yes No

Pacemaker

Yes No

Pneumocystis

Yes No

Psychiatric Problems

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

Yellow Jaundice

Yes No

Do you have any artificial bones?

Yes No

If yes, please list where

Date of Procedure

Physician’s Name

Physician’s Phone Number

Name of Premedication

Have you had an artificial joint replacement?

Yes No

If yes, please list which joint

Date of Procedure

Physician’s Name

Physician’s Phone Number

Name of Premedication

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, over the counter and herbal supplements, 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

Please list any allergy/reaction that you have or have had that is not listed above.

Additional Notes/Comments

Please upload your insurance card and driver's license here

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.

Signature of:

Patient Parent Legal Guardian Agent Under Durable Power of Attorney

First Name

Last Name

Signature of Patient or Guardian

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Date

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