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PATIENT REGISTRATION INFORMATION

Responsible Party


Primary Insurance Company

Who can we thank for referring you to our office?


Health History


Have you had or do you currently have the following:


Allergies/ Reactions

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


Other Health Related Questions


For Women Only

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.

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