Patient Registration

PATIENT REGISTRATION INFORMATION

Patient First Name

Middle Initial

Patient Last Name

Patient Nickname

Gender

Male Female

Date of Birth

Age

SSN

Driver's License #

Email

Address

City

State

Zipcode

Home Phone

Cell Phone

Marital Status

Employer

Occupation

Business Phone

Employment Type

Full Time Part Time

Length of Employment

Primary Physician

Practice Phone

Dentist

Practice Phone

Spouse or Parent Information

First Name

Last Name

Relation

SSN

Driver's License #

Date of Birth

Employer

Business Telephone

Who will be responsible for your account?

Other

Responsible Person First Name

Responsible Person Last Name

SSN

Date of Birth

Telephone

Address

City

State

Zipcode

Work Phone

Nearest Relative

First Name

Last Name

Relation

Address

City

State

Zipcode

Home Phone

Work Phone

Who can we thank for referring you to our practice?

Referral Name

Home Phone

Other

Insurance Information

Do you have dental insurance coverage?

Yes No

Primary Dental Insurance Company

Policy Holder First Name

Policy Holder Last Name

Relation

SSN

Date of Birth

Address

City

State

Zip Code

Primary Policy Holder Employer

Insurance Company Name

Insurance Company Address

City

State

Zip Code

Policy I.D. #

Group #

Plan Name

Secondary Dental Insurance Company

Do you have medical insurance coverage?

Yes No

Policy Holder First Name

Policy Holder Last Name

Relation

SSN

Date of Birth

Address

City

State

Zip Code

Secondary Policy Holder Employer

Insurance Company Name

Insurance Company Address

City

State

Zip Code

Policy I.D. #

Group #

Plan Name

Health History

Primary reason for this dental appointment

Examination Emergency Consultation

Dental History

Do you have a specific problem?

Yes No

Please describe

Do you have dental examinations on a routine basis?

Yes No

When was your last dental visit?

Do you think you have active decay or gum disease?

Yes No

Do your gums ever bleed?

Yes No

Please discuss

Do you like your smile?

Yes No

Why?

Does food catch between your teeth? Any loose teeth?

Yes No

Do you want to keep your remaining teeth?

Yes No

Do you ever have clicking, popping or discomfort in the jaw joint?

Yes No

Do you brux or grind?

Yes No

Have your past experiences in a dental office always been positive?

Yes No

Do you smoke or chew? Any sores or growths in your mouth?

Yes No

Please discuss

Name of previous dentist (optional)

Date of last full mouth x-rays (16 small films or panoramic)

Medical History

Are you under the care of a physician?

Yes No

Reason for visit?

Physician Name

Physician Phone

Have you ever been hospitalized or had a major operation?

Yes No

Please discuss

Have you ever had a serious injury to your head or neck?

Yes No

Please discuss

Are you on a special diet?

Yes No

Please discuss

Have you had or do you currently have the following:

Abnormal Bleeding

Yes No

AIDS/HIV

Yes No

Drug Addiction/Alcohol Abuse

Yes No

Alzheimer's Disease

Yes No

Allergies (Medicines)

Yes No

Allergies (Pollen/Dust)

Yes No

Anemia

Yes No

Arthritis

Yes No

Aredia I.V.

Yes No

Artificial Heart Valve *

Yes No

Artificial Joint *

Yes No

Asthma

Yes No

Bacterial Endocarditis

Yes No

Blood Disease

Yes No

Bloody Sputum

Yes No

Recent Blood Transfusion

Yes No

Breathing Problem

Yes No

Cancer

Yes No

Chemotherapy

Yes No

Chest Pains

Yes No

Cold Sores

Yes No

Congenital Heart Disorder

Yes No

Convulsions

Yes No

Cortisone Medicine

Yes No

Diabetes

Yes No

Drug Abuse

Yes No

Emphysema

Yes No

Excessive Bleeding

Yes No

Excessive Thirst

Yes No

Ever Taken Fen-phen?

Yes No

Fainting or Dizziness

Yes No

Fever Blister

Yes No

Frequent cough

Yes No

Frequent Diarrhea

Yes No

Glaucoma

Yes No

Genital Herpes

Yes No

Hay Fever

Yes No

Heart Attack/Failure

Yes No

Heart Disease Surgery *

Yes No

Heart Murmur *

Yes No

Hemophilia Bleeding Problem

Yes No

Hepatitis A

Yes No

Hepatitis B or C

Yes No

Herpes

Yes No

High blood pressure

Yes No

HIV Positive

Yes No

Hives or Rash

Yes No

Hypoglycemia

Yes No

Irregular Heart Beat

Yes No

Jaw Joint Pain

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

Nervousness

Yes No

Need Premedication?

Yes No

Night Sweats

Yes No

Heart Pace Maker *

Yes No

Parathyroid Disease

Yes No

Psychiatric Care

Yes No

Pulmonary Shunt

Yes No

X-Ray Treatments (Radiation)

Yes No

Recent Weight Loss

Yes No

Renal Dialysis

Yes No

Rheumatic fever *

Yes No

Rheumatism

Yes No

Scarlet Fever

Yes No

Shortness of Breath

Yes No

Sinus Trouble

Yes No

Sickle Cell Disease

Yes No

Stomach/Intestinal Disease

Yes No

Stroke

Yes No

Swelling of Limbs

Yes No

Tattoos/Body Piercing

Yes No

Thyroid Disease

Yes No

Tuberculosis

Yes No

Tumors/Growths

Yes No

Ulcers

Yes No

Unexplained Fever

Yes No

Venereal Disease

Yes No

Yellow Jaundice

Yes No

Zometa I.V.

Yes No

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

Do you wish to talk to the dentist privately about any problem?

Yes No

Medications

Please list all medications, 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

Acrylic

Yes No

Penicillin

Yes No

Metals

Yes No

Codeine

Yes No

Latex Rubber

Yes No

Allergy/Reactions not listed above

Yes No

Please list allergies

For Women Only

Are you pregnant/trying to get pregnant

Yes No

If you are pregant, 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

Insurance and Payments Agreement

I authorize use of this form for all my insurance. I authorize release information to all of my insurance companies. I authorize my doctor/dentist to act as my agent in helping me obtain payment from my insurance companies. I permit a copy of this authorization to be used in place of the original. If I receive payment directly from my insurance company, I agree to pay the dentist in full at time of service. All recommendation testing is my responsibility.

I am aware that any balance over 30 days may be subject to a service charge of 1 1/2% per month (18% annually). Any court costs or attorney's fees will be added to the total amount due. I understand that I am responsible for my bill and that insurance claims for services do not alter my responsibility to pay my account within the time allowed by this office's credit policy (90 days). I further agree that this contract will remainin force for all services regardless of the date signed. There may be a $50.00 charge for broken appointments within a 24 hour notice. There may be a $35.00 fee for imposed checks returned for any reason.

If Patient is a Minor

Form signed by:

Relationship to Patient:

Date

Signature Of Patient

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