Download Patient Registration

Patient Information
Patient Name:
Mr. Mrs. Ms. Dr.
Date:
FIRST
MI
LAST
Social Security #:
(Preferred Name)
Birth Date:______________ Gender __________
Phone (Home):___________________________ (Work): ___________________________ Ext:
Mobile / Cell Number: ______________ Email:_________________________________________________
Emergency Contact Name/Phone Number______________________________ Relationship________________
Address:
Street
Apartment #
City
State
Zip Code
Referred By:_____________________________________________________________________________________________________
Health Information
Reason for this visit:
Have your ever had any of the following? Please check those that apply:
AIDS/HIV
Allergies
-Metal allergy
-Latex allergy
-Medication allergy
________________
-Food allergy
________________
Anemia
Arthritis
Artificial Joints
Hip, knee, other (circle)
Asthma
Blood Disease
Breathing Problems
-COPD
-Empysema
Cancer (type)
___________________
Diabetes
Dizziness, Fainting
Epilepsy
Excessive Bleeding
Glaucoma
Hay Fever
Head Injury
Heart Disease
Heart Murmur
Heart Valve Issues
Hepatitis
TYPE A B C
High Blood Pressure
Low Blood Pressure
Kidney disease
Liver Disease
Mental Disorders
Mitral Valve Prolapse
Nervous Disorders
Osteoporosis
PregnancyDUE DATE_______
Pacemaker/ DEFIB
Radiation Therapy
Rheumatic Fever
Sinus Problems
Sleep Apnea/Snoring
Smoke/Tobacco
Stomach Issues
Stroke
Thyroid
Tumors
Ulcers/GERD
MEDICATION LIST
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
 Are you taking any medications, vitamins or herbs
Yes
No
If yes, please list above
_
 Are you allergic to Penicillin or other Antibiotics
Yes
No list______________________
 Are you taking Bisposhonates –such as fosamax, prolia etc.
Yes
No
 Are you allergic to aspirin/ibuprofen
Yes
No
 Are you allergic to Narcotics such as CODEINE,VICODIN
Yes
No
 Are you sensitive to Epinephrine? Anesthetics?
Yes
No
 Do you require antibiotic premedication for prosthetic joints, heart valve damage or any other reason?
Yes
No _____________________________________________________________________________
 Have you been admitted to a hospital or needed emergency care during the past two years?
Yes
No
If yes, please explain:
 Are you now under the care of a physician?
Yes
No
If yes, please explain:
 Name of Physician: _______________________________________________ Phone:
 Name of Pharmacy: ____________________________City_______________ State_____ Phone:
 Do you have any health problems that need further clarification?
Yes
No
If yes, please explain:
To the best of my knowledge, all of the preceding answers and information provided are true and correct
_________________________________________________________________ Date:
Signature of patient, parent or guardian
Responsible Party Information
The following is for:
the patient
the person responsible for payment
Name:
Male
Female
Married
Single
Child
Other
Social Security #: ________________________________ Birth Date:
Phone (Home): ________________ (Work): ________________ Ext: ______ Best time to call:
Address:
Street
Apartment #
City
State
Zip Code
Employment Information
The following is for:
the patient
the person responsible for payment
Employer Name:
Occupation:
Address:
,
Street
City , State Zip Code
Phone
Dental Insurance Information
Primary
Name of Insured: ______________________________________________Is insured a patient?
Last
First
Yes
No
MI
Insured's Birth Date: _________________ ID #: _____________________ Group #:
Insured's Address:
______________________________________
Street
City
State
Zip Code
State
Zip Code
Insured's Employer Name:
Address:
Street
Patient's relationship to insured:
City
Self
Spouse
Child
Other ___________________
Insurance Plan Name and Address:
Secondary Insurance Information
Name of Insured: ______________________________________________ Is insured a patient?
Last
First
Yes
No
MI
Insured's Birth Date: _________________ ID #: _____________________ Group #:
Insured's Address:
Street
City
State
Zip Code
Insured's Employer Name:
Address: ________________________ ___________________________________________________
Street
Patient's relationship to insured:
City
Self
Spouse
Child
State
Zip Code
Other ___________________
Insurance Plan Name and Address:
Consent for Services
As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon
reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must
be determined before treatment.
All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for at
the time services are performed.
Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that
he or she is personally responsible for payment of all dental services. This office will help prepare the patients insurance
forms or assist in making collections from insurance companies and will credit any such collections to the patient's account.
However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.
I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form.
I have read the above conditions of treatment and agree to their content.
____________________________________________________ Date: _____________ Relationship to Patient:
Signature of patient, parent or guardian