Patient Registration

First Name

Last Name

Middle Initial

Patient Is

Policy Holder

Responsible Party

Preferred Name

Responsible Party ( if someone other than the patient)

First Name

Last Name

Middle Initial

Address

Address 2

City

State

Zip

Home Phone

Phone Phone

Cell Phone

Date of Birth

Social Security

Driver's License

Responsible Party is also a Policy Holder for Patient

Primary Insurance Policy Holder

Secondary Insurance Policy Holder

Patient Information

Address

Address 2

City

State

Zip

Home Phone

Phone Phone

Cell Phone

Birth Date

Age

Social Security

Driver's License

Email address

I would like to receive correspondences via e-mail.

Medicaid ID

Employer ID

Carrier ID

Preferred Dentist

Preferred Pharmacy

Preferred Hygienist

Due for Recall

How did you hear about our office?

Primary Insurance Information

Add new row

Secondary Insurance Information

Add new row

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

2021 Update Medical Form

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Are you under a physician's care now?

Yes No

If yes, Explain

Have you ever been hospitalized or had a major operation?

Yes No

If yes, Explain

Have you ever had a serious head or neck injury?

Yes No

If yes, Explain

Are you taking any medications, pills, or drugs?

Yes No

If yes, Explain

Do you take, or have you taken, Phen-Fen or Redux?

Yes No

If yes, Explain

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

Yes No

If yes, Explain

Are you on a special diet?

Yes No

Do you use tobacco?

Yes No

Do you use marijuana (Medical or recreational)?

Yes No

If yes, how often?

Do you use controlled substances?

Yes No

If yes, how often?

Woman: Are you....

Are you allergic to any of the following?

Aspirin

Metal

Penicillin

Latex

Codeine

Sulfa Drugs

Acrylic

Local Anesthetics

Other

If Other, Please Explain

Do you have, or have you had, any of the following?

AIDS/HIV Positive

Yes No

Alzheimer's Disease

Yes No

Anaphylaxis

Yes No

Anemia

Yes No

Angina

Yes No

Arthritis / Gout

Yes No

Artificial Heart Valve

Yes No

Artificial Joint

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

Yellow Jaundice

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

Spina Bifida

Yes No

Stomach / Intestinal Disease

Yes No

Stroke

Yes No

Swelling of Limbs

Yes No

Thyroid Disease

Yes No

Tonsillitis

Yes No

Tuberculosis

Yes No

Tumors or Growths

Yes No

Ulcers

Yes No

Venereal Disease

Yes No

Have you tested Positive for COVID-19

Yes No

If yes, Please Explain

Have you ever had any serious illness not listed above?

Yes No

If yes, Please Explain

Comments

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.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

To attach a copy of your license and/or insurance card or any other information.

Add file

Please upload a file

Your information will be encrypted.

Patient Registration

Responsible Party ( if someone other than the patient)

Patient Information

Primary Insurance Information

Secondary Insurance Information

2021 Update Medical Form

Woman: Are you....

Do you have, or have you had, any of the following?

To attach a copy of your license and/or insurance card or any other information.

River Forest Dental Studio