• Paul Y. Lin, D.D.S.

    Cosmetic, Restorative, & General Dentistry

  • PATIENT REGISTRATION FORM

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: 000 - 00 - 0000.
  • Format: 00000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Do You Have A Dental Insurance*

  • DENTAL INSURANCE INFORMATION

  • This Dental Insurance Is Covered Through (Please Select One)

  • IF YOU ARE COVERED THROUGH SOMEONE OTHER THAN YOURSELF, PLEASE COMPLETE THIS SECTION FOR THE PRIMARY INSURED (PRIMARY SUBSCRIBER).

  •  - -
    2 digit month, 2 digit day, 4 digit year
  • Format: 000 - 00 - 0000.
  • Do You Have a Secondary Dental Insurance?
  • The Secondary Insurance Is Covered Through (Select One)

  • SECONDARY INSURANCE COVERAGE:

  • IF YOU ARE COVERED THROUGH SOMEONE OTHER THAN YOURSELF, PLEASE COMPLETE THIS SECTION FOR THE PRIMARY INSURED (PRIMARY SUBSCRIBER).

  •  / /
    2 digit month, 2 digit day, 4 digit year
  • Format: 000 - 00 - 0000.

  • Whom May We Thank for Referring You to Our Office

  • Paul Y. Lin, D.D.S.

    Cosmetic, Restorative, & General Dentistry 

  • PATIENT MEDICAL HISTORY

  • Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have or medications that you may be taking could have an important interrelationship with the treatment you will receive in our office. Thank you for answering the following questions.

  • 1. Are you under a physician’s care and receiving treatment now?*
  • 2. Have you ever been hospitalized or had major surgery?*
  • 3. Have you ever had a serious head or neck injury? *
  • 4. Are you taking any medications, pills, or drugs?*
  • 5. Do you take, or have you taken, Phen-Fen or Redux?*
  • 6. Do you take, or have you taken Bisphosphonate (Fosamax)? *
  • 7. Are you on a special diet?*
  • 8. Do you use tobacco? *
  • 9. Do you use controlled substances? *
  • 10. FEMALE PATIENTS ONLY. Please check if any of the following conditions apply?
  • 11. ARE YOU ALLERGIC TO ANY OF THE FOLLOWING? (Please check all that apply)
  • 12. DO YOU HAVE, OR HAVE YOU HAD, ANY OF THE FOLLOWING CONDITIONS? (Please check all that apply)

  • IF YOU HAVE EVER HAD ANY SERIOUS ILLNESS OR CONDITION NOT LISTED ABOVE. PLEASE EXPLAIN

  • COMMENTS OR ANYTHING ELSE WE SHOULD BE AWARE OF?

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  • Please contact the office for any questions or issues.

    82 Townsend Street,

    San Francisco, CA 94107

    Tel.415. 543.6882

    info@PaulYLinDDS.com

    www.PaulYLinDDS.com

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