Patient Registration Form

Fill out this form or download and print it to bring on the date of your appointment

    Patient Registration

    ID:

    Chart ID:

    First Name:

    Last Name:

    Middle Initial:

    Patient Is:
    Preferred Name:

    Responsible Party ( if someone other than the patient )

    First Name:

    Last Name:

    Middle Initial:

    Address:

    Address 2:

    City, State, Zip:

    Pager:

    Home Phone:

    Work Phone:

    Ext:

    Cellular:

    Birth Date:

    Soc Sec:

    Drivers Lic:

    Patient Information

    Address:

    Address 2:

    City:

    State, Zip:

    Pager:

    Home Phone:

    Work Phone:

    Ext:

    Cellular:

    Sex:

    Marital Status:

    Birth Date:

    Age:

    Soc Sec:

    Drivers Lic:

    E-mail:

    Section 2

    Employment Status:

    Student Status:

    Medicaid ID:

    Pref. Dentist:

    Employer ID:

    Pref. Pharmacy:

    Carrier ID:

    Pref. Hyg:

    Section 3

    Referred By:

    Previous Dentist:

    Emergency Contact

    Emergency Contact #

    Care Credit #

    Primary Insurance Information

    Name of Insured:

    Relationship to Insured:

    Insured Soc. Sec:

    Insured Birth Date:

    Employer:

    Address:

    Address 2:

    City, State, Zip:

    Ins. Company:

    Address:

    Address 2:

    City, State, Zip:

    Rem. Benefits:

    Rem. Deduct:

    Secondary Insurance Information

    Name of Insured:

    Relationship to Insured:

    Insured Soc. Sec:

    Insured Birth Date:

    Employer:

    Address:

    Address 2:

    City, State, Zip:

    Ins. Company:

    Address:

    Address 2:

    City, State, Zip:

    Rem. Benefits:

    Rem. Deduct:

    Medical History

    Patient Name:

    Birth Date:

    Date Created:

    Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication you may be taking,

    Are you under Physician's care now?:

    If Yes, Please provide Name, Phone number:

    Have you ever been hospitalised or had a major operation?:

    If Yes:

    Have you ever had a serious head or neck injury?:

    If Yes:

    Are you taking any medications, pills, or drugs?:

    If Yes:

    Do you take, or have you taken Phen-Fen or Redux?:

    If Yes:

    Have you ever taken Fosamax, Boniva, Actonel, or any other medications containing bisphosphonates?:

    If Yes:

    Women: Are you...

    Are you allergic to any of the following?

    Do you use controlled substances?:

    If Yes:

    Other?:

    If Yes:

    Do you have, or have you had, any of the following?

    AIDS/HIV Positive:

    Alzheimer's Disease:

    Anaphylaxis:

    Anemia:

    Angina:

    Arthritis/Gout:

    Artificial Heart Valve:

    Artifical Joint:

    Asthma:

    Blood Disease:

    Blood Transfusion:

    Breathing Problems:

    Bruise Easily:

    Cancer:

    Chemotherapy:

    Chest Pains:

    Cold Sores/Fever Blisters:

    Congential Heart Disorders:

    Convulsions:

    Yellow Jaundice:

    Cortisone Medicine:

    Diabetes:

    Drug Addiction:

    Easily Winded:

    Emphysema:

    Epilespy or Seizures:

    Excessive Bleeding:

    Excessive Thrust:

    Fainting Spells/Dizziness:

    Frequent Coughs:

    Frequent Diarrhea:

    Frequent Headaches:

    Genital Herpes:

    Gloucoma:

    Hay Fever:

    Heart Attack/Failure:

    Heart Murmur:

    Heart Pacemaker:

    Heart Trouble/Disease:

    Hemophilia:

    Hepatitis A:

    Hepatitis B or C:

    Herpes:

    High Blood Pressure:

    High Cholesterol:

    Hives or Rash:

    Hoipoglycemia:

    Irregular Heart Beat:

    Kidney Problems:

    Leukemia:

    Liver Disease:

    Low Blood Pressure:

    Lung Disease:

    Mitral Valve Prolapse:

    Osteoporosis:

    Pain in Jaw Joint:

    Parathyroid Disease:

    Psychiatric Care:

    Radiation Treatments:

    Recent Weight Loss:

    Renal Dialysis:

    Rheumatic Fever:

    Rheumatism:

    Scarlet Fever:

    Shingles:

    Sickle Cell Disease:

    Sinus Trouble:

    Spina Bifida:

    Stomach/Intestinal Disease:

    Stroke:

    Swelling of Limbs:

    Thyroid Disease:

    Tonsillitis:

    Tuberculosis:

    Tumors or Growths:

    Ulcers:

    Venereal Disease:

    Have you ever had any serious illness not listed above?:

    If Yes:

    Comments

    To best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

    Date: