reg

Dental Registration and History

Please complete every section below as accurately as possible. Fields marked * are required.

1 Patient Information

Date SS/HIC/Patient ID # Last Name First Name Middle Initial Address City State Zip E-mail Sex Age Birthdate Marital Status Partnered for (years) Patient Employer/School Occupation Employer/School Address Employer/School Phone Spouse's Name Spouse's Birthdate Spouse's SS# Spouse's Employer Whom may we thank for referring you?

2 Dental Insurance

Who is responsible for this account? Relationship to Patient Insurance Co. Group # Is patient covered by additional insurance? Subscriber's Name Subscriber's Birthdate Subscriber's SS# Relationship to Patient Insurance Co. Group #

Assignment and Release

I certify that I, and/or my dependent(s), have insurance coverage with the company named below and assign directly to the dentist named below all insurance 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 authorize the use of my signature on all insurance submissions. The above-named dentist may use my health care information and disclose it to the above-named insurance company for the purpose of obtaining payment and determining benefits. This consent ends when my current treatment plan is completed or one year from the date signed below.

Name of Insurance Company(ies) Dr. (name of dentist) Signature (type full name) Date Relationship to Patient

3 Phone Numbers

Home Phone Work Phone Ext Cell Phone Spouse's Work Phone Best time and place to reach you

In case of emergency, contact (someone who does not live in your household)

Name Relationship Home Phone Work Phone

4 Dental History

Reason for today's visit Former Dentist City/State Date of last dental visit Date of last dental X-rays

Please indicate if you have had any of the following:

How often do you floss? How often do you brush?

5 Health History

Physician's Name Date of last visit

Have you ever taken any of the "fen-phen" group of drugs (lonimin, Adipex, Fastin, Pondimin, Redux)? Yes No

Please indicate if you have had any of the following:

Do you wear contact lenses? Yes No

Women

Are you pregnant? Yes No

Are you nursing? Yes No

Taking birth control pills? Yes No

Due date

6 Medications List any medications you are currently taking and the correlating diagnosis

Pharmacy Name Pharmacy Phone

7 Allergies

Aspirin Barbiturates (Sleeping pills) Codeine Iodine Latex Local Anesthetic Penicillin Sulfa Other: