|
PATIENT REGISTRATION
AND MEDICAL HISTORY
Date ____________________________ (PLEASE
PRINT) Home Phone(___)_________________________
Patient _________________________________________________________________________
Last Name First
Name Middle
Preferred
Name
Street Address_______________________________City_______________State____Zip
Code______
Occupation_______________________________________Social
Security No.___________________
Sex M F Age________
Birthdate________ __Single
_Married _Widowed _ Separated _ Divorced
Employed by _____________________________________ Occupation
________________________________
Business Address __________________________________ Business Phone ____________________________
Spouse/Parent Name_________________________________ Spouse/Parent Birthdate______________________
Spouse/Parent Employed by ___________________________ Occupation
_______________________________
Business Address __________________________________ Business Phone ____________________________
Who is responsible for this account? ____________________ Relationship
to Patient _______________________
Social Security #____________________________________
Spouse/Parent Social Security # ________________
Name of the Dental Insurance Company __________________ Group Number
_____________________________
In case of emergency, who should be notified? _____________ Phone ___________________________________
Whom may we thank for referring you? ___________________________________________________________
Medical History
Physician's Name ____________________________________
Date of Last Physical ______________________
Have you ever had any of the following?
(Check that apply):
| __ Heart Murmur |
__ Epilepsy |
__ Special Diet |
| __ High Blood Pressure |
__ Headaches |
__ Swollen Neck Glands |
| __ Low Blood Pressure |
__ Hepatitis, Jaundice or Liver Disease |
__ Rheumatic Fever |
| __ Circulatory Problems |
__ Cancer |
__ Sinus Problems |
| __ Nervous Problems |
__ Psychiatric Care |
__ AIDS/HIV |
| __ Radiation Treatment |
__ Mistral Valve Prolapse |
__ Thyroid Disease |
| __ Artificial Heart Valves or Joints |
__ Allergies to Anesthetics |
__ Stroke |
| __ Recent Weight Loss |
__ Allergies to Medicine or Drugs |
__ Ulcer |
| __ Back Problems |
__ General Allergies |
__ Venereal Disease |
| __ Diabetes |
__ Blood Disease |
__ Chemical Dependency |
| __ Respiratory Disease |
__ Arthritis |
__ Hemophillia |
Do you have any drug allergies of have
you ever had an adverse reaction to any medication? ___________________
If so, what? _________________________________________________________________________________
Have you ever responded adversely to medical or dental treatment? ______________________________________
Are you taking any medication at this time? ___________________ If
so, what? ____________________________
Are you under the care of a physician? ___ Yes ___ No For
what condition? _____________________________
If patient is a child, what is his/her weight? _________________________________________________________
(Women) Do you suspect that you are pregnant? __ Yes __
No Are you nursing? __ Yes __ No
Is there anything else we should know about your medical history?_______________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
The above information is accurate and complete to the best of my knowledge
and is only for use in my treatment, billing and processing of insurance
for benefits for which I am entitled. I will not hold my dentist or
any member of his/her staff responsible for any errors or omissions
that I may have made in the completion of this form.
Date __________________________ Signature
_____________________________________________________
ASSIGNMENT AND RELEASE
I, the undersigned, have insurance with
_____________________________________________________________
Name
of the Insured Company(ies)
and assign directly to Dr. _______________________, all benefits, if
any otherwise payable to me for services rendered. I understand that
I am financially responsible for all charges whether or not paid by
insurance. I hereby authorize the doctor to release all information
necessary to secure the payment of benefits. I authorize the use of
this signature on all my insurance submissions whether manual or electronic.
____________________________ ____________________________________________________
Date Signature
MINOR/CHILD CONSENT
I, being the parent or guardian of _________________________________
do hereby request and authorize the dental
Name
of the Minor / Child
staff to perform necessary dental services for
my child, including but not limited to X-rays, and administration of
anesthetics which are deemed advisable by the doctor, whether or not
I am present at the actual appointment when the treatment is rendered.
____________________________ ____________________________________________________
Date Signature
of Insured/Guardian
FINANCIAL AGREEMENT
I acknowledge that payment is due at the
time of treatment, unless other arrangements are made. I agree that
parents/guardians are responsible for all fees and services rendered
for treatment of a minor/child. I accept full financial responsibility
for all charges not covered by insurance.
____________________________ ____________________________________________________
Date Signature
of Insured/Guardian
MEDICAL HISTORY UPDATE
Has there been any change in your health
since your last dental appointment? __
Yes __ No
For what conditions?_________________________________________________________________________
Are you taking any new medications?____________________________________________________________
If so, what? ________________________________________________________________________________
____________________________ ___________________________________________________
Date Patient
Signature
___________________________ ____________________________________________________
Date Dentist
Signature
|