_2017 Adult Registration Form – Dental Patient Information* Patient Name: (Required) Gender: Male Female Social Security Number:Birth Date:Age:Home Address: City: State: Zip: Primary Phone Number: Phone Type home cell OK to leave message? Yes No E-mail:Employer's Name:Occupation:Spouse / Partner InformationSpouse/Partner's Name: Marital Status: Single Married Divorced Widowed Significant OtherSocial Security Number:Birth Date:Driver's License Number: Address (if different than patient):City:State:Zip:Primary Phone:Phone Type: home cell Secondary Phone:Phone Type: home cell Emergency Contact InformationEmergency Contact's Name:Phone Number:Relation to Patient:Address:City: State:Zip: Person(s) OK to release appointment or medically-related information to: Relation to Patient:Insurance InformationPrimary InsurancePrimary Insurance Company:Phone Number:Group Number:Policy Number:Member ID Number:Co-pay (if known):Deductible (if known):Policy Holder's Name:Relation to Patient:Policy Holder's SSN:Policy Holder's Date of Birth:Employer:Work Phone Number:Secondary InsuranceSecondary Insurance Company:Phone Number:Group Number:Policy Number:Member ID Number:Co-pay (if known):Deductible (if known):Policy Holder's Name:Relation to Patient:Policy Holder's SSN:Policy Holder's Date of Birth:Employer:Work Phone Number:Dental HistoryHow did you hear about our practice? Ad Internet Family/Friend Physician Other Name of person referring(if applicable) : Have your tonsils or adenoids been removed? Yes NoHave you ever experienced jaw joint pain/discomfort (TMJ/TMD)? Yes NoDo you have any missing or extra permanent teeth? Yes NoHave you ever had an injury to (select all that apply): Teeth Mouth ChinDo you have speech problems? Yes NoIf so, explain:Do your gums bleed? Yes NoDo you smoke? Yes NoDo you like your smile? Yes NoDo you currently or have you ever had any of the following habits(check all that apply): Clenching/Grinding Teeth Lip Sucking/Biting Mouth Breathing Nail Biting Thumb/Finger Sucking Chewing/Eating ProblemMedical HistoryAre you currently being treated by a physician? Yes No Reason: Physician: Last Visit: Phone: Do you have any allergies/sensitivities to medications or latex? Yes NoIf yes, please list: Are you currently taking any prescription or over-the-counter medications? Yes NoIf yes, please list with the dosage: Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)? Yes NoHave you had any serious illnesses or operations? If yes, describe: Have you ever had a blood transfusion? Yes NoIf yes, give approximate dates: (Women) Are you pregnant? Yes NoNursing? Yes NoTaking birth control pills? Yes NoCheck if you have ever had any of the following: Anemia Arthritis, Rheumatism Artificial Heart Valves Artificial Joints Asthma Back Problems Blood Disease Cancer Chemical Dependency Chemotherapy Circulatory Problems Cortisone Treatments Cough, Persistent Coughing Blood Diabetes Epilepsy Fainting Glaucoma Headaches Heart Murmur Heart Problems Hemophilia Hepatitis High Blood Pressure HIV/AIDS Jaw Pain Kidney Disease Liver Disease Mitral Valve Prolapse Pacemaker Radiation Treatment Respiratory Disease Rheumatic Fever Scarlet Fever Shortness of Breath Skin Rash Stroke Swelling of Feet or Ankles Thyroid Problems Tobacco Habit Tonsilitis Tuberculosis Ulcer Venereal Disease (STD)AuthorizationI 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 understand that where appropriate, credit bureau reports may be obtained.Submitted by: Date: Security Measuregoogle recaptcha