Patient Registration Form

Patient Information

Date

SS/HIC/Patient ID #

Patient Name

Address

City

State

Zip

Date of Birth

Age

If Partnered, for how many years?

Occupation / School

Occupation

Employer / School

Address

Number

Spouse Name

Date of Birth

SS#

Employer

Whom may we thank for referring you?

Contact Information

Home

Work

Ext

Cell

Best time and place to reach you

Emergency Contact

Name

Relationship

Home

Work

Dental Insurance

I certify that I, and/ or my dependent(s) have insurance coverage with

and assign directly to Dr.

All insurance benefits, if any , otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named doctor may use my health care information and may disclosed such information to the above named insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits of the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

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 of Patient / Guardian / Personal Representative

Date

Relationship to Patient

Dental History

Reason For Visit

Former Dentist

City/State

Date of Last Dental Visit

Date of Last Dental X-Rays

How often do you floss?

How often do you brush?

Other comments

Medical History Form

Patient Name

Birth Date

Date Created

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.

Are you under a physician's care now?

Yes No

If yes, Please describe

Have you ever been hospitalized or had a major operation?

Yes No

If yes, Please describe

Have you ever had a serious head or neck injury?

Yes No

If yes, Please describe

Are you taking any medications, pills,or drugs?

Yes No

If yes, Please describe

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

Yes No

If yes, Please describe

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

Yes No

If yes, Please describe

Are you on special diet?

Yes No

Do yo use tobacco?

Yes No

Women: Are you?

Pregnant / Trying to get pregnant?

Nursing?

Taking Oral Contraceptives?

Are you allergic to any of the following?

Aspirin

Metal

Penicillin

Latex

Codeine

Sulfa Drugs

Acrylic

Local Anesthetics

If other, please specify

Do you use controlled substances?

Yes No

If yes, please describe

Have you ever had any serious illness not listed

Yes No

If yes, Please specify

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.

Signature of Patient, Parent or Guardian

Date

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