Patient Registration And Medical History

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Date___________________               (PLEASE PRINT)                        Home Phone______________                                                 
Patient____________________________________________________________________________________________________
               Last Name                               First Name                                   Initial                           Preferred Name         
Street Address__________________________________    City__________________  State______________  Zip_______________

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 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 boxes that apply):
Heart Problems

High Blood Pressure

Low Blood Pressure

Circulatory Problems

Nervous Problems

Radiation Treatment

Artificial Heart Valves or Joints

Recent Weight Loss

Back Problems

Diabetes

Respiratory Disease

Epilepsy

Headaches

Hepatitis, Jaundice or Liver Disease

Cancer

Psychiatric Care

Chronic Diarrhea

Allergies to Anesthetics

Allergies to Medicine or Drugs

General Allergies

Blood Disease

Arthritis

Special Diet

Swollen Neck Glands

Rheumatic Fever

Sinus Problems

"A.I.D.S." or Other Immunosuppressive Disorders

Stroke

Ulcer

Venereal Disease

Chemical Dependency

Hemophilia
Do you have any drug allergies or have you ever had an adverse reaction to any medication?___________  If so, what______________
Are you taking any medication at this time?_______  If so, what_______________________________________________________
Are you under the care of a physician?    Yes   No

For what conditions?_________________________________________________________________________________________

If patient is a child, what is his/her weight?________________________________________________________________________
(Women)  Do you 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 authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me, my spouse, or my child during the period of such Dental care to third party payors and/or other health practioners.  I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me.  I understand that my dental insurance carrier may pay less than the actual bill for services.  I agree to be responsible for payment of all services rendered to myself, my dependents or spouse.

____________________________________________________          ________________________________________________ 

Signature of patient or parent if minor                                                                                 Date
FINANCIAL ARRANGEMENTS

For your convenience, we offer the following methods of payment.  Please check the option which you prefer.  Co-Payment due in full at each appointment.

_______Cash

_______Personal Check

_______Credit Card _____Visa _____MC _____Discover

_______Pride Direct

_______Northwest Financial

_______I wish to discuss the dental office's policy.

__________________________________________________________

Signature of patient or parent is minor

 

Late Charges

If I do not pay the entire new balance within 25 days of the monthly billing date, a late charge of 1.5% on the balance then unpaid and owed will be assessed each month (if allowed by law).  I realize the failure to keep this account current may result in you being able to provide additional dental services except for dental emergencies or where there is prepayment for additional services.  In the case of default on payment of this account, I agree to pay collection costs and reasonable attorney fees incurred in attempting to collect on this amount or any future outstanding account balances.

 

 

_____________________

Date
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                                                                                                Signature of patient or parent if minor

 

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