Patient Registration And Medical History Form - Glacier Valley Endodontics

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PATIENT REGISTRATION
AND MEDICAL HISTORY FORM
Patient’s Full Name: __________________________________________ circlee
Male
Female
Mailing Address: ______________________________ City: __________ State: _______ Zip: ________
Marital Status: circlee
M S W D Birth Date: ______________ SSN ________________________
Home Phone #: ______________________Spouse’s Name: ______ SSN ________________________
Spouse’s Birth Date: ___________________________________________________________________
Person responsible of account: circlee
Self
Spouse
Parent*
Other*
*If parent or Other, please list name, address, employer, phone #, S.S.#, birth date and insurance on the back of this sheet.
Your Employer:
Name: ___________________
Address: _______________________________
Phone: ___________________
Position: _______________________________
Spouse’s Employer: Name: ____________________
Address: _______________________________
Phone: ___________________
Position: _______________________________
Where may we leave a message: circlee
Home
Work
Other ______________________________
Primary Dental Insurance Company: _______________________________________________________
Carrier (Family Member) _____________________ Group # ________________Agreement # ________
Referring Dentist: _________________________________ How long have you been his/her patient? ___
Is this Appointment for:
circlee
Consultation
Treatment
Both
Have you or any family member been a patient here? circlee
No
Yes
When Who_________
Are you in pain?
circlee
No
Yes
Has your dentist prescribed any medication?
circlee
No
Yes
List
Have you previously had a root canal?
circlee
No
Yes
When_________
In case of emergency contact ________________________________ Phone _____________________
PERMISSION FOR X-RAYS, CONSULTATION AND/OR ROOT CANAL PROCEDURES
To the best of my knowledge, all answers on this form are correct. I will notify the doctor of any changes in
my health or medications.
I, the undersigned, consent to the dental procedures decided upon to be necessary or advisable in the
opinion of the doctor, of which I am informed and to which I agree.
I also understand that only the root canal treatment is to be completed at this office. The permanent (out-
side) restoration (filling, inlay, crown, etc.) will be performed by my general dentist.
How will you be paying for your treatment today?
circlee Visa
Mastercard
Am. Exp.
Discover
Check # _____
Cash
SIGNATURE: _________________________________________________ Date: ___________________

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