Patient Information/registration Form printable pdf download

Harmony Dental Arts

1066 Clifton Avenue

Tel

973-

777-2731

Clifton, NJ 07013

Fax 973-777-1077

PATIENT

INFORMATION:

Name: _______________________________________________ DOB: _______________ SS#: ____________________

Mailing Address: ___________________________________________City, State, Zip: ____________________________

Home #: __________________________ Work #: __________________________Cell #: __________________________

EMAIL: ___________________________________________________________________________________________

EMPLOYER & Address: ______________________________________________________________________________

ACCOUNT RESPONSIBILITY if someone other than yourself:

Name: _______________________________________________ DOB: _______________ SS#: ____________________

Mailing Address: ___________________________________________City, State, Zip: ____________________________

Whom may we thank for referring you? : _________________________________________________________________

Reason for today’s visit: _______________________________________________________________________________

DENTAL

INSURANCE:

Name of Ins. Company: _______________________________________________________________________________

If you are not the primary policy holder, please enter policy holder’s information below:

Name: _______________________________________________ DOB: _______________ SS#: ____________________

EMPLOYER & Address: ______________________________________________________________________________

NOTICE OF PRIVACY

PRACTICE: The privacy of your health information is important to us. During your initial

visit, please review the notice of privacy practices regarding uses and disclosures of your health information.

INSURANCE

POLICY: If you have dental insurance, we will send the claim electronically for you, and have the

reimbursement sent directly to Harmony Dental Art. We will estimate your portion and ask that you take care of it

at the time of service. Any balance remaining after insurance pays is the responsibility of the patient.

DENTAL

HISTORY:

?áYes ? No

Bad Breath

Bleeding Gums

Clicking/ Popping Jaw

?áYes ?bNo

Jaw Pain

Orthodontic Treatment

Periodontal Treatment

HEALTH

HISTORY:

AIDS/HIV?áYes ?§No

Chemotherapy ?áYes ?§No

Mitral Valve Prolapse ?áYes ?§No

Arthritis ?áYes ? No

Congenital Heart Lesions ?áYes ? No

Oral Herpes ?áYes ? No

Artificial Heart Valves ?áYes ?bNo

Cough (Persistent/Bloody) ?áYes ?bNo

Pacemaker ?áYes ?bNo

Artificial Joints ?áYes ?•No

Diabetes ?áYes ?•No

Psychiatric Care ?áYes ?•No

Asthma ?áYes ?@ No

Epilepsy ?áYes ?@ No

Rheumatic Fever ?áYes ?@ No

Blood Disease ?áYes ?ùNo

Heart Murmur ?áYes ?ùNo

Smoking ?áYes ?ùNo

Blood Pressure ?áYes ?³ No

Heavy Bleeder ?áYes ?³ No

Tuberculosis ?áYes ?³ No

Cancer ?áYes ?t No

Hepatitis (Type ______) ?áYes ?t No

Other ?áYes ?t No

Chemical Dependency ?áYes ?. No

Kidney/Liver Disease ?áYes ?. No

Please list other: _______________

List any and all ALLERGIES:

?á

Codeine

?á

Latex

?á

Local

?á

Anesthetic

?á

Penicillin

?á

Other _______________________

DRUGS/MEDICATIONS

List any and all

you are taking:

____________________________________________________

The above information is true and correct to the best of my knowledge:

PATIENT SIGNATURE: ___________________________________________________

DATE: __________________________

Patient Information/registration Form

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