coastal-endo.com - Patient Registration

REGISTRATION
Date

MonthDayYear
Date
Patient’s Name

First NameMiddle NameLast Name
Mr.Mrs.Ms.Dr.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Prefer:

HomeWorkCell
Nickname (if any)
Patient SS #
Date of Birth

MonthDayYear
Date
Employer
Email
example@example.com
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician
Office #
If patient is a minor - Guardian name
DOB

MonthDayYear
Date
SS #
Whom may we contact in case of an emergency?
Phone
Please enter a valid phone number.Format: (000) 000-0000.
DENTAL HISTORY
Referred Today By
Reason
General Dentist
Last Seen by him/her
Have you had previous root canal therapy?

YesNo
If yes, when?
Are you having any pain?

YesNo
If yes, please grade on scale of 1-5
(1 being dull pain- 5 being severe)
For how long?
Circle which of the following sensitivities that apply to you today:

HotColdBiting PainThrobbing
RECEIPT OF ACKNOWLEDGMENT OF AUTHORIZATION
Please sign below to indicate that you are aware that the Notice of Privacy Practice Act information is accessible to you upon request.
Signature
Date

MonthDayYear
Date
*Please indicate below whom, other than your General Dentist/ Referring Doctor we can speak with in reference to your medical treatment, insurance questions, account information, and general messages (ex. Appointments, etc…):
I AUTHORIZE DETAILED MESSAGES TO BE LEFT ON MY: (PLEASE CIRCLE ALL THAT APPLY)

Home Phone #Work Phone #Cell Phone #
Name
Relationship
Tel. #
Please enter a valid phone number.Format: (000) 000-0000.
Name
Relationship
Tel. #
Please enter a valid phone number.Format: (000) 000-0000.
PATIENT HEALTH HISTORY
Date

MonthDayYear
Date
Name:
PregnantFatigueSwelling/EdemaAnemia/BleedingImmunocompromisedHerpesVenereal DiseaseInfectious DiseaseHigh Blood PressureHypertension/CirculaHeart DiseaseHeart Murmur/DefectPacemakerHeart Attack/StrokeIrregular Heart BeatAnginaHigh CholesterolRheumatic FeverDiabetesThyroidCancerRadiation/ChemoTuberculosisArthritisJoint ReplacementProsthetic ImplantAny TransplantSmokeShortness of BreathHypoglycemiaEl Ulcers/DigestiveMigraines/HeadacheEpilepsy/FaintingGlaucoma/VisualMental/NeuralDepressionAlcoholism/AddictionTMJAsthmaOther
Allergies

No Medical AllergiesAntibioticsPenicillinTylenolCodeineNarcoticsLocal AnesthLatexValium/TranquilNitrous OxideFoodsBleachIodine/SeafoodSulfaAspirinSeasonalOther
Medications

No MedicationsAntibioticPain MedicineHeart MedicineAspirinCortisone/SteriodsBlood ThinnerBlood PressureHormoneThyroidBirth Control PillsInsulinUlcer/NexiumBone RelatedAntidepressantsRelaxantsCholesterolVitaminsSleep AidsOther
**Please list ALL medications**
The information above is correct.
Name
Date

MonthDayYear
Date
Pharmacy
Pharmacy Phone #
Please enter a valid phone number.Format: (000) 000-0000.
I confirm that I am NOT presenting any of the following symptoms of COVID-19 listed below:

FeverShortness of BreathDry CoughRunny NoseSore Throat
Initials*
Should be Empty:

REGISTRATION

DENTAL HISTORY

RECEIPT OF ACKNOWLEDGMENT OF AUTHORIZATION

PATIENT HEALTH HISTORY