PATIENT REGISTRATION

First Name : Last Name : Middle Initail :
Patient Is : Policy Holder
                 Responsible Party
Preferred Name :

Responsible Party (if someone other than the patient)

First Name : Last Name : Middle Intial :
Address : Address 2:
City,State,Zip : Pager :
Home Phone : Work Phone : Ext : Cellular :
Birth Date : Soc Sec : Drivers Lic :
Responsible Party is also a Policy Holder Patient : Primary Insurance Policy Holder : Secondary Insurance Policy Holder :

Patient Information

Address : Address 2 :
City : State/Zip : Pager :
Home Phone : Work Phone : Ext : Cellular :
Sex : M F
Martial status : Married Single Divorced Separated Widowed
Birth Date : Age : Soc Sec : Drivers Lic. :
Email : I would like to receive correspondences via email :
Section 2
Employment Status : Full Time Part TimeRetired
Student Status : Full Time Part Time
Medicaid ID : Pref. Dentist :
Employer ID : Pref. Pharmacy :
Carrier ID: Pref.Hyg :
Section 3
Additional Comments

Primary Insurance Information

Name of insured : Relationship to insured : Self Spouse Child Other
Insured Soc Sec : Insured Birth Date :
Employer :
Address :
Address 2:
City,State,Zip :
Rem Benefits :
Ins. company :
Address :
Address 2 :
City,State,Zip :
Rem Deduct :

Secondary Insurance Information

Name of insured : Relationship to insured : Self
Spouse
Child
Other
Insured Soc Sec : Insured Birth Date :
Employer :
Address :
Address 2:
City,State,Zip :
Rem Benefits :
Ins. company :
Address :
Address 2 :
City,State,Zip :
Rem Deduct :



MEDICAL HISTORY REGISTRATION

PATIENT NAME : Birth Date :
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 mediccation that you may be taking .could have an impportant interrelationship with the dentistry you will receive .Thank You for answering the following Question.
Are You Under a physician's care now?
Yes No
If yes,please explain :
Have you ever been hospitalized or
had a major operation ? Yes No
If yes ,please explain :
Have you ever had a serious head
or neck injury? Yes No
If yes ,please explain :
Are you taking any medications,
pills or drugs?Yes No
If yes ,please explain :
Have you ever had a serious head or neck injury?
Yes No
Do you take, or have you taken,Phen-Fen or redux?
Yes No
Have you ever taken Fosamax,Boniva,Actonel or any other medications containing bisphosphonates? Yes No
Are you on a special diet? Yes No
Do you use tobacco? Yes No
Do you use controlled substances? Yes No
Women Are you
Pregnant/Trying to get pregnant?
Yes No
Taking oral contraceptives ?
Yes No
Nursing ?
Yes No
Are you allergic to any of the following ?
Aspirin Penciillin Codeine Local Anesthetics Acrylic Metal Latex Sulfa drugs
Other If yes,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
Asthama
Yes No
Blood Disease
Yes No
Blood Transfusion
Yes No
Breathing Problem
Yes No
Bruise Easily
Yes No
Cancer
Yes No
Chemotherapy
Yes No
Chest Pains
Yes No
ColdScores/Fever Bilsters
Yes No
CongentialHeart Disorder
Yes No
Convulsions
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
: NYes 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 Mummur
Yes No
Heart Peacemaker
Yes No
Heart Trouble/
Disease
Yes No
Hemophilia
Yes No
Hepatitis A
Yes No
Hepatitis B or C
Yes No
Herpes
Yes No
HighBlood 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
MitralValve Prolapse
Yes No
Osteoporosis
Yes No
Pain in Jaw Joints
Yes No
Parathyroid Disease
Yes No
Psythyroid Care
Yes No
Radiation
Yes No
Recent Weight Loss
Yes No
Renal Dialysis
Yes No
Rtheumatic Fever
Yes No
Rtheumatism
Yes No
Scarlet Fever
Yes No
Shingles
Yes No
Sickle Cell Disease
Yes No
Sinus Trouble
Yes No
Spina Bifida
Yes No
Stomach/Intenstinal 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 Disea
Yes No
Have you ever had any serious illness not listed above ?
Yes No
Comments :


To the best of my knowledge, the question 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 responsiblilty to inform the dental office of any changes in medical status
Signature Of Patient,Parent, Or Guardian : Date :

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