Patient Registration Form

We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have questions we’ll be glad to help you. We look forward to working with you in maintaining your dental health.

Name:

Soc. Sec #:

Address:

City:

State:

Zip:

Home Phone #:

Cell Phone #:

Email address:

Sex:

Male Female

Age:

Birthdate:

Marital Status:

Single Married Widowed Separated Divorced Child

Patient Employed by:

Occupation:

Business Address:

City:

State:

Zip:

Business Phone:

Business Email Address:

If Full Time Student School Name:

Whom may we thank for referring you?

Person Responsible for Account:

Relationship to Patient:

Primary Insurance

Insurance Company Name:

Phone:

Insured’s Name:

Relationship to Patient:

Insured’s ID #:

Insured’s Date of Birth:

Insured’s Employer:

Employer’s Phone #:

Work Address:

City:

State:

Zip:

Group #:

Effective Date:

Secondary Insurance

Insurance Company Name:

Phone:

Insured’s Name:

Relationship to Patient:

Insured’s ID #:

Insured’s Date of Birth:

Insured’s Employer:

Employer’s Phone #:

Work Address:

City:

State:

Zip:

Group #:

Effective Date:

Authorization

I have reviewed the information on the front and back of this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate and healthful dental treatment. If there is any change in my medical status, I will inform the dentist.

I authorize the insurance company indicated on this form to pay to the dentist all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions.

I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.

I grant permission to David Schmidt, D.D.S., to use my name, photograph, video, audio recording, and/or testimonial in marketing or teaching materials used for his dental practice, including Dr. Schmidt’s website. Check the box no if you do not agree.

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

Signature:

Date:

Payment is due in full at the time of treatment unless prior arrangements have been approved.

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.

Dental History

What would you like us to do today?

Are you in dental discomfort today?

Former Dentist:

Date of last dental care:

Date of last x-rays:

How often do you brush?

How often do you floss or use toothpicks?

How do you feel about the appearance of your teeth?

Have you ever experienced an adverse reaction during or in conjunction with a medical or dental procedure?

Yes No

Other information about your dental health or previous treatment.

Notify in case of emergency:

Email address:

Home Phone:

Cell Phone:

Business Phone:

Medical History

Physician’s name:

Phone:

Date of last visit:

Have you had any serious illness or operations?

Yes No

If yes, describe:

Are you currently under physician care?

Yes No

If yes, describe:

Have you ever had a blood transfusion?

Yes No

If yes, describe:

Have you ever taken Fen-Phen/Redux?

Yes No

Women: Are you pregnant or trying to get pregnant?

Yes No

Nursing:

Yes No

Taking birth control pills?

Yes No

If Heart Problems is chosen, please describe:

What medication, vitamins or herbal supplements are you taking?

Does patient have drug allergies? If yes, list all:

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

Signature:

Date:

Your information will be encrypted.