Patient Registration

Chart ID

First Name

Last Name

Middle Initial

Preferred Name

Responsible Party (if someone other than the patient)

First Name

Last Name

Middle Initial

Address

Address 2

Home Phone

Work Phone

Ext

Cellular Phone

Birth Date

Soc Sec

Drivers License

Responsiblle 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

Work Phone

Ext

Cellular Phone

Date

Age

Soc. Sec

Drivers License

E-mail

I would like to receive correspondences via e-mail

Section 2

Medical ID

Pref. Dentist

Employer ID

Pref. Pharmacy

Carrier ID

Pref. Hyg.

Section 3

Pharmacy Name

Pharmacy Number

Mom's Name

Dad's Name

Middle Initial

Additional Information

Primary Insurance Information

Name of Insured

Insured Soc. Sec

Insured Birth Date

Employer

Address

Address 2

City, State, Zip

Rem. Benefits

Rem. Deduct

Ins. Company

Address

Address 2

City, State, Zip

Secondary Insurance Information

Name of Insured

Insured Soc. Sec.

Insured Birth Date

Employer

Address

Address 2

City, State, Zip

Rem. Benefits

Rem. Deduct

Ins. Company

Address

Address 2

City, State, Zip

Eaglesoft Medical History

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

Have you ever been hospitalized or had a major operation?

Yes No

If yes

Have you ever had a serious head or neck injury?

Yes No

If yes

Are you taking any medications, pills, or drugs?

Yes No

If yes

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

Yes No

If yes

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

Yes No

If yes

Are you on a special diet?

Yes No

Do you 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

Penicillin

Codeine

Acrylic

Metal

Latex

Sulfa Drugs

Local Anesthetics

Do you use controlled substances?

Yes No

If yes

If other, please specify

Have you ever had any serious illness not listed

Yes No

If yes

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 of Patient, Parent or Guardian

Date

Your information will be encrypted.