Patient Registration

PATIENT REGISTRATION INFORMATION

Date

Mr. Mrs. Ms. Dr.

Patient First Name

Middle Initial

Patient Last Name

Patient Nickname

Gender

Male Female

Date of Birth

Age

SSN

Email address

If you do not have an email address, please put "None".

Address

City

State

Zipcode

Home Phone

Cell Phone

Occupation

Marital Status

Employment Status

Not Employed Full Time Part Time Retired

Employer

Business Phone

Personal Payment Type

Cash Check Credit Card

Emergency Contact

Emergency phone

Relation

Spouse or parent information:

Name

Relation

SSN

Date of Birth

Home Phone

Cell Phone

Address

City

State

Zipcode

Business Phone

Occupation

Employer

Insurance Information

Primary Insurance Company

What type of Insurance do you have?

Dental Medical None

Primary Policy Holder

Relation

Gender

Male Female

SSN

Date of Birth

Address

City

State

Zip Code

Telephone

Primary Policy Holder Employer

Business Address

Business Telephone

Insurance Company Name

Insurance Company Address

Telephone

Policy I.D. #

Group #

Group Name

Secondary Insurance Company

Do you have secondary insurance?

Yes No

Insurance Type

Dental Medical

Secondary Policy Holder

Relation

Gender

Male Female

SSN

Date of Birth

Address

City

State

Zip Code

Telephone

Secondary Policy Holder Employer

Business Address

Business Telephone

Insurance Company Name

Insurance Company Address

Telephone

Policy I.D. #

Group #

Group Name

Dental Information

Reason for today's visit?

Are you in pain?

Yes No

For how long?

Please indicate any of the following by checking the appropriate box:

Do you have a toothache?

Yes No

Severity

Swelling

My teeth are sensitive

Swelling

Mild Moderate Severe

My teeth are sensitive to:

Hot Cold Sweets Biting

Other

Prior treatment on tooth or area in question:

Date of last dental appointment:

What was done at that time?

Date and purpose of next dental appointment:

General Dentist

Phone

Dental Specialist

Phone

Have you ever been a patient of our practice?

Yes No

Whom may we thank for referring you to our office?

Health History

Are you in good health?

Yes No

Are you under the care of a physician?

Yes No

Nature of Treatment

Have you had any illness, operation, or hospitalization in past five years?

Yes No

Has there been any change in your general health within the past five years?

Yes No

Please specify

Have you been hospitalized within the past five years?

Yes No

Reason

Have you received therapy for alcoholism or drug addiction during the past five years?

Yes No

Have you ever been tested for HIV infection (AIDS)?

Yes No

Result of test:

Positive Negative

Date of test:

Date of last physical exam:

Have you had or do you currently have the following:

High blood pressure

Yes No

Rheumatic fever

Yes No

Prosthetic heart valve

Yes No

Asthma

Yes No

Sinus trouble

Yes No

Hepatitis, jaundice, liver disease

Yes No

Fainting Spells or seizures

Yes No

Tuberculosis

Yes No

Heart murmur or mitral valve prolapse (MVP)

Yes No

Congenital heart disease

Yes No

Blood disorder (e.g. anemia)

Yes No

Temporomandibular joint problems (TMJ)

Yes No

Diabetes

Yes No

Kidney problems

Yes No

Epilepsy

Yes No

Joint prosthesis

Yes No

Cardiovascular disease (heart attack, stroke)

Yes No

Venereal disease

Yes No

Thyroid problems

Yes No

Stomach ulcers, colitis

Yes No

Psychiatric treatment

Yes No

Cancer

Yes No

Please list any disease, condition, or problem not listed above:

Please list any current medication(s) you are taking (including non-prescription medication)

Allergies/ Reactions

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

Penicillin

Yes No

Iodine

Yes No

Aspirin

Yes No

Latex

Yes No

Local anesthetic

Yes No

Codeine or other narcotics

Yes No

Other antibiotics

Yes No

Please list antibiotic allergies

Please list any other medications that you are allergic to:

For women only

Is there a possibility of pregnancy?

Yes No

Expected delivery date

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 / gynecologist for assistance regarding additional methods of birth control.

FORM COMPLETION

I certify that I have read and I understand the questions above. I will not hold the doctors of Perry Endodontics, P.C. or any other member of their staff, responsible for any errors or omissions that I have made in the completion of this form.

Signature of Patient (Parent or Guardian if Minor)

Clear

Clear

Reviewed by

Date

Fees and Payments

All fees are due upon completion of treatment. I hereby authorize payment to Perry Endodontics, P.C. of the benefits otherwise payable to me. If you have any dental and/or medical insurance we will be glad to fill out the proper forms, but please complete the identifying information on this form.

Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge.

It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid for by your insurance company. You will be responsible for all collection costs, attorneys fees, and court costs.

Signature of Patient (Parent or Guardian if Minor)

Clear

Clear

Date

This signature on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment to Perry Endodontics, P.C.of the benefits otherwise payable to me.

Signature of Patient (Parent or Guardian if Minor)

Clear

Clear

Date

I hereby acknowledge that a copy of this office's Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions I may have regarding this Notice.

Signature of Patient (Parent or Guardian if Minor)

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Clear

Date