Quietcornerdental.com

Do you now have or have you ever had any of the following: Prosthetic heart valve, cardiac transplantation.! Osteoporosis treated with medication .! ! Medical condition requiring hospitalization.! Medical condition treated by your physician.! Please answer these questions. Use the space below if you need more.
Please list any medicines you are taking.___________________________________Have you ever taken a bisphosphonate medication such as: Boniva, Fosamax, Zometa, Didronel, Skelid, Actonel, Aredia? If yes please circle the medicine.
Have you ever been hospitalized? If so, for what?___________________________Are you receiving treatment from your physician? If so, for what?______________Who is your physician? Where is the office?_______________________________What is the reason for your visit?_________________________________________ Signature:___________________________________Date:_____________________ Adult Registration
Today’s Date:___________________Name:________________________________________________Birthdate:_____________Age:___________Male:______Female:______Spouse’s Name:_____________________________________eMail Address:___________________________________Residence Address:___________________________________City:_________________State:________Zip:________Mailing Address (only if differs from residence):________________________________City:_________________State:________Zip:________Social security number:________________________________Phone-home:_____________Phone-work:_____________Phone-Cell:_____________How would you prefer to be contacted for appointment confirmation? ! Employed by:_______________________Referred by:__________________________Who will pay this account ?______________________________In case of emergency provide the name and phone number of someone not at your home whom we might contact.__________________________________________ Insurance Information
Please provide name, social security number and date of birth of insured person if it differs
from information above:_________________________________________
Name and address of dental insurance company:
Primary:________________________________________
________________________________________
! Policy#________________________________
Secondary:_______________________________________
_________________________________________
!
I will review proposed treatment plans and authorize release of any information related to insurance claims. I understand that I am responsible for all costs of dental treatment.
Sign:_____________________________________Date:__________________I hereby authorize payment of the dental benefits otherwise payable to me directly to Dr. McGinn.
Does your child now have or have you ever had any of the following: Liver disease, hepatitis.! ___! ___! ___Heart Disease.! ___! ___! ___Heart murmur.! Pacemaker.! ___! ___! ___High blood pressure.! Sinus disease.! ___! ___! ___Radiation treatment.! Lupus.! ___! ___! ___Allergy to any medicines.! Medical condition requiring hospitalization.! Medical condition treated by your physician.! Pregnancy (check only if you are expecting now).! Please answer these questions. Use the space below if you need more.
Please list any medicines your child is taking._________________________________Has your child ever been hospitalized? If so, for what?__________________________Is your child receiving treatment from your physician? If so, for what?______________Who is your child’s physician? Where is the office?_____________________________What is the reason for this visit?_________________________________________ Signature:___________________________________Date:_____________________ Child Registration
Today’s Date:___________________Child’s Name:________________________________________________Birthdate:_____________Age:___________Male:______Female:______Parent’s Name:_____________________________________Residence Address:___________________________________City:_________________State:________Zip:________Mailing Address:____________________________________City:_________________State:________Zip:________Child’s social security number:________________________________Phone-home:_____________Phone-Cell:_____________Mother’s Employer:___________________Work Telephone:_______________Father’s Employer:___________________Work Telephone:_______________How would you prefer to be contacted for appointment confirmation? ! Who will pay this account ?______________________________ Insurance InformationName and address of dental insurance company: Primary:________________________________________ ________________________________________ ! Policy#________________________________! Name of insured:_______________________Date of birth:_________________ Social Security number of insured:___________________ Secondary:_______________________________________ _________________________________________! Name of insured:_______________________Date of birth:_________________ Social Security number of insured:___________________ I will review proposed treatment plans and authorize release of any information related to insurance claims. I understand that I am responsible for all costs of dental treatment.
Sign:_____________________________________Date:__________________I hereby authorize payment of the dental benefits otherwise payable to me directly to Dr. McGinn.
Sign:_____________________________________Date:__________________

Source: http://www.quietcornerdental.com/assets/docs/new_patient_registration.pdf