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Thank You!
Your registration has been sent to our office.
Name
*
Patient's Birthday
SS#
Address
City
Zip
Home #
Cell #
Business #
E-mail
Marital Status
Spouse's Name (Parent or Guardian if Minor)
Employer
Other family members living at same address
Responsible Party
Emergency Contact
Telephone
Person Providing Insurance
Insured Birth date
Dental Insurance Company Name
Policy/Group #
Insured Employer's Name
Insured SS#
Insurance Co Address
Ins Co Phone #
As a courtesy to our patients, we are happy to submit all insurance claims at no charge. It is up to the patient to fully understand their insurance benefits and to be responsible for that portion of the account that the insurance does not pay.
What prompted you to see dental care at this time?
Reason for leaving former dentist
Referred By
How long since you have been to a Dentist?
Since had dental X-rays?
Previous Dentist name to call for X-rays?
Previous Dentist Phone #
Have you ever been treated for periodontal (gum) disease?
Yes
No
Do you grind or clench your teeth?
Yes
No
Are you in good health?
Yes
No
Are you presently under the care of a physician?
Yes
No
Explain
Are you taking any medications?
Yes
No
(i.e. Coumadin, Bloodthinners, Cortison, Insuline, Digitalis, Dilantin, Fosamax)
List
Do you have or have you ever had any of the following diseases or problems?
Surgery
Stroke
Drug Allergies or Adverse Drug Reactions
Heart Disease
Anemia or Blood Disorders
Depression
Heart Murmur/Mitrai Valve Prolapse
Gastro Intestinal
Veneral Disease/Herpes
Rheumatic Fever
Respiratory Disease (Asthma)
AIDS/ARC/HIV+
Cancer
Diabetes
Convulsions or Epilepsy
High or Low Blood Pressure
Hepatitis/Jaundice/Liver Disease
Latex Allergy
Osteoporosis
Thyroid
NONE OF THE ABOVE
Please click one that applies
Have you had abnormal bleeding associated with previous extractions, surgery or trauma?
Yes
No
Do you have any prosthetic replacements?
Yes
No
(i.e Hip, Knee, Heart Valve)
Have you ever been required to take antibiotics prior to dental procedures?
Yes
No
Comments
Signature
Upon signing, I understand that I will be charged 1.5% per month (18% annually) on all unpaid balances 90 days past due.
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