Adult Registration Form

_2017 Adult Registration Form – Dental

Patient Information

Gender:
Phone Type

 Cell Phone Number:

Would you like text message appointment notifications?Yes No

Spouse / Partner Information

Marital Status:

Emergency Contact Information

 

Insurance Information

Primary Insurance

Policy Holder's Name:

Secondary Insurance

Policy Holder's Name:

Dental History

How did you hear about our practice?
Have your tonsils or adenoids been removed?
Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)?
Do you have any missing or extra permanent teeth?
Have you ever had an injury to (select all that apply):
Do you have speech problems?
Do your gums bleed?
Do you smoke?
Do you like your smile?
Do you currently or have you ever had any of the following habits(check all that apply):

Medical History

Are you currently being treated by a physician?
Preferred Pharmacy and town it's located in:
Do you have any allergies/sensitivities to medications or latex?
Are you currently taking any prescription or over-the-counter medications?
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
Do you need to Premedicate for Dental Appointments?Yes No
 
(Women) Are you pregnant?
Nursing?
Taking birth control pills?
Check if you have ever had any of the following:

Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status.

I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I am also aware that there is a fee associated for all appointments cancelled or broken without 24 hours notice. The fee will be a minimum $25 for a hygiene visit and $50 for a doctor visit per person scheduled.

I understand that where appropriate, credit bureau reports may be obtained.



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