Please print this page and fill out the questions listed below.  Having this information complete will make your registration more efficient, as well as ensure that your personal and/or insurance/billing information is correct.

 

PATIENT INFORMATION

Name:  ____________________________________________________________________

Address: _______________________________ City: ____________________ State:_________ Zip: _________________

Home Phone: ___________________ Work Phone: __________________ Ext: _______ Cellular: __________________________

Sex: [] Male [] Female  

Marital Status: [] Married [] Single [] Divorced [] Separated [] Widowed

Birth Date: ____/____/_____ Age: ______ Soc. Sec: ____-____-_____ Driver’s Lic: ___________________

 

Employment Status: [] Full Time [] Part Time [] Retired    Student Status: [] Full Time [] Part Time, Occupation:_______________________

Emergency Contact Name: ______________________________ Emergency #: ___________________

Whom may we thank for referring you to our office? ____________________________________________________

Name of primary dentist: ___________________________

 

RESPONSIBLE PARTY (if someone other than patient)

First Name: ______________________ Last Name: __________________ Middle Initial: __________

Address: _________________________________________ City: ____________________ State:__________ Zip: _____________ Home phone: _____________________ Cell: ______________ Work: ________________________ Ext: ____________

Birth Date: ________________ SS #: ____-___-_____ Driver’s License #: ______________________________State: ___________

Employer/Occupation: ____________________________________ Work Phone: __________________

 

BENEFIT INFORMATION

Primary Benefit Information

Name of Insured: _____________________________ Relationship to insured:

[] Self [] Spouse [] Child [] other

Insured Soc. Sec: ____-____-_____ Insured Birth Date: ____/____/_____ Employer: ____________________________

Ins. Company: ____________________________Subscriber I.D.:_________________________ Group #:_____________________

Address: _______________________________________ City: ____________________ State: _______ Zip: _________

 

Secondary Benefit Information

Name of Insured: _____________________________ Relationship to insured: [] Self [] Spouse [] Child [] other

Insured Soc. Sec: ____-____-_____ Insured Birth Date: ____/____/_____ Employer: ____________________________

Ins. Company: ____________________________ Subscriber I.D.: ________________________ Group #: _____________________

Address: _______________________________________ City: ____________________ State: _______ Zip: ______

 

MEDICAL HEALTH HISTORY

Do you have or have you had any of the following? (Please check any that apply)

 Cancer or tumor  ____

 Heart disease  ____

 Heart murmur, mitral valve prolapse  ____

 Rheumatic fever or rheumatic heart disease  ____

 Artificial joint or valve  ____

 High or low blood pressure  ____

 Pacemaker  ____

 Tuberculosis or other lung problems  ____

 Kidney disease  ____

 Hepatitis or other liver disease  ____

 Alcoholism or dry dependency  ____



Are you allergic to:

 Latex materials  ____

 Penicillin or other antibiotics  ____

 Local anesthetics ("Novocain")  ____

 Codeine or other narcotics  ____

 Sulfa drugs  ____

 Barbiturates, sedatives, or sleeping pills  ____

 Aspirin  ____

 Other: _____________________________________

 

 

 

Women:  May be pregnant __________    Expected delivery date: _______________

 

Name of your physician: __________________________________ Last Visit Date: _________________

Do you have any disease, condition, or problem not listed above?

___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________

Please add any other medical or health related issues:

___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________

 

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 _________________

 

    Diabetes  ____

 

 Emotional condition  ____

 Arthritis  ____

 Herpes or cold sores  ____

 AIDS or HIV positive  ____

 Migraine headaches or frequent headaches  ____

 Anemia or blood disorders  ____

 Abnormal bleeding ____

 Hay fever or sinus trouble  ____

 Asthma  ____

     Fainting, epilepsy  ____

Are you taking any of the following?

 Aspirin  ____

 Anticoagulants (blood thinners)  ____

 Antibiotics or sulfa drugs  ____

 High blood pressure medicine  ____

 Antidepressants or tranquilizers  ____

 Insulin, Orinase, or other diabetes drug  ____

 Nitroglycerin  ____

 Cortisone or other steroids  ____

 Osteoporosis (bone density) medicine  ____

 Other:_____________________________________