PATIENT REGISTRATION AND MEDICAL HISTORY

PATIENT REGISTRATION AND MEDICAL HISTORY

(Please Print)
Date

Month Day Year
Date
Home Ph
Cell Ph
Email
example@example.com
Patient
Address

Street Address

Street Address Line 2

State

Zip
Sex

M F
Age
Birthdate

Month Day Year
Date
Married Widowed Separated Divorced Single
Employed By
Occupation
Spouse/Parent Name
Spouse/Parent DOB

Month Day Year
Date
Spouse/Parent Employed By
Occupation
Who is responsible for this account?
Relationship to Pt
Social Sec #
Spouse/Parent Social Sec #
Dental Insurance Company
Grp #
In case of emergency, who should be notified?
Ph
Whom may we thank for referring you?
MEDICAL HISTORY
Physician's Name
Date of last physical

Month Day Year
Date
Have you ever had any of the following? (Check all _✔_ that apply.)
Heart Murmur High Blood Pressure Low Blood Pressure Circulatory Problems Nervous Problems Radiation Treatment Artifical Heart Valve OR Joints Recent Weight Loss Back Problems Diabetes Respiratory Disease Epilepsy Headaches Mitral Valve Prolapse Hepatitis, Jaundice or Liver Disease Cancer Psychiatric Care Allergies to Anesthetics Allergies to Medicines or Drugs General Allergies Blood Disease Arthritis Special Diet Swollen Neck Glands Rheumatic Fever Sinus Problems AIDS/HIV Thyroid Disease Stroke Ulcer Venereal Disease Chemical Dependency Hemophilia
Do you have any drug allergies or have you ever had an adverse reaction to any medication?
If so,what
Have you ever responded adversely to medical or dental treatment?
Are you taking any medications at this time?

Yes No
(If yes, please list on the next page provided.)
Are you under the care of a physician?

Yes No
For what condition(s)
If the patient is a child, what is his/her weight?
(Women) Do you suspect that you are pregnant

Yes No
Are you nursing?

Yes No
Is there anything else we should know about your medical history?
The above information is accurate and complete to the best of my knowledge and is only for use in my treatment, billing & processing of insurance for benefits for which I am entitled. I will not hold my dentist or any member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form.
Signature

Clear
Date

Month Day Year
Date
Assignment and Release
I, the undersigned, have insurance with Name of Insurance Company(s) and assign directly to Dr. Eric J. Sadler, DDS, PA and Dr. David R.J. Plummer, DDS, PA all benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions whether manual or electronic.
Signature

Clear
Date

Month Day Year
Date
MINOR/CHILD CONSENT
I, being the parent or guardian of Name of Insurance Company(s) fdo hereby request and authorize the dental staff to perform necessary dental services for my child, including but not limited to x-rays, and administration of anesthetics which are deemed advisable by the provider, whether or not I am present at the actual appointment when the treatment is rendered.
Signature

Clear
Date

Month Day Year
Date
FINANCIAL AGREEMENT
I acknowledge that payment is due at the time of treatment, unless other arrangements are made. I agree that parents/guardians are responsible for all fees and services rendered for treatment of a minor/child. I accept full financial responsibility for all charges not covered by insurance.
Signature

Clear
Date

Month Day Year
Date
Should be Empty:

PATIENT REGISTRATION AND MEDICAL HISTORY

MEDICAL HISTORY

Assignment and Release

MINOR/CHILD CONSENT

FINANCIAL AGREEMENT