Patient Registration Form

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2014
Patient Registration
Date __________________
Patient Name __________________________________________________ Birthdate _____________________ Age______
First
Middle
Last

 Single
 Married  Other _____________________________
SS#________________________________________
Home Address________________________________________________________________________ Zip ______________
Home Number (____)______________________________ Work Number (____)____________________________________
Cell Phone (____)_________________________________E- Mail Address _________________________________________
How did you hear about us? _______________________________________________________________________________
Employer Name
Occupation_____________________________ Work #_____________________________________________________
Person Responsible for Account
Relationship
Social Security #
Home # (
)__________D/O/B ____________________________________
Home Address (if different)
State
Zip
_
Insurance Company Name and Address
______________________________________________________________________________________________________
Group #_______________________________Subscriber #______________________Phone#__________________________
Dental History
 Routine Checkup
 Appearance  Pain Avoidance
 Cavities
What are your concerns? Mark all that apply:
 Losing Teeth
 Oral Cancer  Gum/Periodontal Disease Braces
How often do you brush?_________________________How often do you floss?___________________________________________
Former Dentist______________________________Date of last dental visit____________________Date of last dental x-rays________________
Medical Information
Physician’s name__________________________________________Date of last visit_________________________________
Have you had any serious illnesses or operations?_________If yes, describe_________________________________________
Check the appropriate box if you have or have had any of the following:
 Heart Ailment
 Rheumatic Fever
 Stroke
 Psychiatric Treatment
 Mitral Valve Prolapse
 Blood Disease
 Liver Disease
 Are You Pregnant
 High Blood Pressure
 Kidney Disease
 Diabetes
 Hepatitis
 Respiratory Disease
 Tumors or Growths
 Glaucoma
 HIV+
 Stomach / Intestinal Disease
 Epilepsy / Convulsions
 Tuberculosis
 Seizures
 Thyroid Trouble
 Abnormal Bleeding
 Fainting / Dizziness
 Anemia / Leukemia / Low Platelets
 Prostate Trouble
 Rheumatism or Arthritis
 Asthma / Hay Fever
 Other____________________________________
 Organ / Valve / Joint / Replacement and/or Implant: Type: ________________________________________________
In case of emergency, whom should we contact?_______________________________________________________________
Medications
Are you taking any medications? _________List Medications:______________________________________________________
Are you allergic to: Aspirin Codeine Penicillin Sulfa Latex Local Anesthetic Other_________________________
 I acknowledge that I have been given or offered a copy of the offices “Notice of Privacy Practices.”
I Understand That Payment Is Due At Time Of Service.
I will pay today by:  CASH
 CHECK
 CREDIT CARD
 OTHER
Signature: _____________________________________________
Date: _____________________
Our office is committed to meeting or exceeding the standards of infection control mandated by the OSHA, th e CDC and the ADA.

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