Patient registration associates in family dentistry, llc

PATIENT REGISTRATION

Last Name: _________________________ First Name: _______________________
Preferred Name: __________________________ Address: _________________________________________________________________________________________________________ Cell Phone: _______________________________ Marital Status:  Married  Single  Divorced  Separated  Widowed Employment Status:  Full Time  Part Time  Self Employed  Retired  Unemployed Referred By: ______________________________
Responsible Party (if different from patient)
Relationship to Patient: _____________________ Address: _________________________________________________________________________________________________________ Cell Phone: _______________________________ Social Security: _____________________ Driver’s Lic #: _____________________________ Primary Insurance Information:
Name of Insured: _________________________________
Relationship to Insured:  Self  Spouse  Child  Other Employer ID: ____________________________________ Carrier ID: _____________________________________________________ Insured Social Security #: __________________________ Insured Birth Date: _______________________________________________ Employer: ______________________________________ Insurance Company: ______________________________________________ Address: _______________________________________ Address: _______________________________________________________ City, State, Zip: _________________________________ City, State, Zip: _________________________________________________
Secondary Insurance Information:
Name of Insured: _________________________________
Relationship to Insured:  Self  Spouse  Child  Other Employer ID: ____________________________________ Carrier ID: _____________________________________________________ Insured Social Security #: __________________________ Insured Birth Date: _______________________________________________ Employer: ______________________________________ Insurance Company: ______________________________________________ Address: _______________________________________ Address: _______________________________________________________ City, State, Zip: _________________________________ City, State, Zip: _________________________________________________ Medical History
Patient Name: ____________________________________________ Birth Date: ______________________ Although Dental Personnel primarily treat the area in and around your mouth is part of your entire body. Heath problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions. Are you under a physician’s care now? ______________________________________________________________________________ Have you ever been hospitalized or had a major operation? Yes No If yes, please explain: ________________________________________________________________________________ Have you ever had a serious head or neck injury? ________________________________________________________________________________ Are you taking any medications, pills or drugs? _______________________________________________________________________________ _____________________________________________________________________________________________________________ Do you need to pre-medicate for heart or joint replacements? Yes No If yes, please explain: ___________________________________ Do you take, or have you taken Boniva or Fosamax? Women: Are you pregnant/Trying to get pregnant?  Yes  No Taking oral contraceptives?  Yes  No Nursing:  Yes  No Are you allergic to any of the following?  Penicillin Please list any other drugs that you are allergic to: ________________________________________________________________________ Why have you come to the dentist today? _________________________________________ Are you currently in pain?  Yes  No Date of your last dental treatment ____/____/____ Do you experience stress or anxiety when you visit a dental office?  Yes  No Have you ever had a serious or difficult problem associated with any previous dental treatment?  Yes  No Have you ever been treated for gum disease?  Yes  No Do your gums bleed now?  Yes  No Do you now or have you ever experienced any pain or discomfort in your jaw joint (TMJ)?  Yes  No Do you now have or have you ever had any of the following? AIDS or HIV + Have you ever had any serious illness not listed above? ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ Comments/Concerns:_______________________________________________________________________________________________________________________________________________________________________________________________________________ To the 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. Signature of Patient, Parent, or Guardian _____________________________________ Date _____________________________________ In Case of Emergency, contact _____________________________________________ Phone _____________________________________

Source: http://www.associatesinfamilydentistry.net/Health%20History%202013%20pdf.pdf