Adult Patient Information

Adult Registration Form - Dental
* required field

PATIENT INFORMATION







Primary Phone Number *
Secondary Phone Number


EMERGENCY CONTACT INFORMATION

Marital Status






INSURANCE INFORMATION











SECONDARY DENTAL INSURANCE











How did you hear about our practice?

DENTAL HISTORY

Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)?
Have you ever had an injury to (select all that apply):
Are your teeth sensitive to cold, hot, sweets or pressure?
Have you had any periodontal (gum) treatments?
Are you currently experiencing dental pain or discomfort?
Do you currently or have you ever had any of the following habits?

MEDICAL HISTORY

Are you currently being treated by a physician?


Are you taking or have you recently taken any prescription or over the counter medicines?
Are you taking or scheduled to begin taking any of these medications, Alendronate (Fosamax) or Risedronate (Actonel) for osteoporosis or Paget's disease?
Since 2001, were you treated or are you presently scheduled to begin treatment with intravenous bisphosphonates (Aredia or Zometa) for bone pain, hypercalcemia or skeletal complications resulting from Paget's disease, multiple myeloma or metastatic cancer
JOINT REPLACEMENT: Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement?
Do you use tobacco products?
If so, how interested are you in stopping?

WOMEN ONLY

Are you pregnant?
Nursing?
Taking birth control pills or hormonal replacement?

ALLERGIES

Do you have any allergies/sensitivities to medications or latex?
Local anesthetics
Penicillin or other antibiotics
Metals

Check if you have or have ever had any of the following:




























Has a physician recommended that you take antibioitcs prior to your dental treatment? *
Do you have any other disease, condition or problem not listed above that you think we should know about?

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




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