Hall of Fame Dental Patient Registration and History

DENTAL REGISTRATION AND HISTORY
PATIENT INFORMATION
Date

MonthDayYear
Date
SS/HIC/Patient ID #
Patient Name

First NameMiddle NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState

Zip Code
Sex
Age
AGE
Birthdate

MonthDayYear
Date
Marital Status
Patient Employer/School
Occupation
Employer/School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer/School Phone
Please enter a valid phone number.Format: (000) 000-0000.
Spouse's Name

First NameLast Name
Birthdate

MonthDayYear
Date
SS#
Who were you referred by? (Optional)
DENTAL INSURANCE
Who is responsible for this account?
Relationship to Patient
Insurance Co.
Group #
Is the patient covered by additional insurance?
Subscriber's Name
Birthdate

MonthDayYear
Date
SS#
Relationship to Patient
Insurance Co.
Group #
ASSIGNMENT AND RELEASE
I certify that I, and/or my dependent(s), have insurance coverage with Name of Insurance Company(ies) and assign directly to Dr. Davis and Dr. Motiu all insurance 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 authorize the use of my signature on all insurance submissions.

The above-named dentist may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.
Signature of Patient, Parent, Guardian or Personal Representative
Please print name of Patient, Parent, Guardian or Personal Representative
Date

MonthDayYear
Date
Relationship to Patient
PHONE NUMBERS
Home
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work
Please enter a valid phone number.Format: (000) 000-0000.
EXT
Spouse's Work
Please enter a valid phone number.Format: (000) 000-0000.
“Best time to reach you?”
IN CASE OF EMERGENCY, CONTACT (Specify someone who does not live in your household.)
Name

First NameLast Name
Relationship
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
DENTAL HISTORY
Reason for today's visit
Former Dentist
City/State

CityState

Zip Code
Date of last dental visit

MonthDayYear
Date
Date of last dental X-rays

MonthDayYear
Date

Place a mark on "yes" or "no" to indicate if you have had any of the following:

Rows	Yes	No
Bad breath
Bleeding gums
Blisters on lips or mouth
Burning sensation on tongue
Chew on one side of mouth
Cigarette, pipe, or cigar smoking
Clicking or popping jaw
Dry mouth
Fingernail biting
Food collection between the teeth
Foreign objects
Grinding teeth
Gums swollen or tender
Jaw pain or tiredness
Lip or cheek biting
Loose teeth or broken fillings
Mouth breathing
Mouth pain, brushing
Orthodontic treatment
Pain around ear
Periodontal treatment
Sensitivity to cold
Sensitivity to heat
Sensitivity to sweets
Sensitivity when biting
Sores or growth in your mouth

How often do you floss?
How often do you brush?
HEALTH HISTORY
Physician's Name
Physician's Name
Date of last visit

MonthDayYear
Date
Have you ever taken any of the group of drugs collectively referred to as “fen-phen?”These include combinations of lonimin, Adipex, Fastin (brand names ofphentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine).

Place a mark on "yes" or "no" to indicate if you have had any of the following:

Rows	Yes	No
AIDS/HIV
Anemia
Arthritis, Rheumatism
Artificial Heart Valves
Artificial Joints
Asthma
Back Problems
Bleeding abnormally, with extractions or surgery
Blood Disease
Cancer
Chemical Dependency
Chemotherapy
Circulatory Problems
Congenital Heart Lesions
Cortisone Treatments
Cough, persistent or bloody
Diabetes
Emphysema
Respiratory Disease
Rheumatic Fever
Scarlet Fever
Shortness of Breath
Sinus Trouble
Skin Rash
Special Diet
Stroke
Swollen Feet or Ankles
Swollen Neck Glands
Thyroid Problems
Tonsillitis
Tuberculosis
Tumor or growth on head or neck
Ulcer
Venereal Disease
Weight Loss, unexplained
Do you wear contact lenses?

Women:
Are you pregnant?
Due date

MonthDayYear
Date

Rows	Yes	No
Are you Nursing?
Taking birth control pills?

MEDICATIONS
List any medications you are currently taking and the diagno-sis:
Pharmacy Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
ALLERGIES

Other
Should be Empty:

DENTAL REGISTRATION AND HISTORY

PATIENT INFORMATION

DENTAL INSURANCE

PHONE NUMBERS

DENTAL HISTORY

HEALTH HISTORY

Women:

MEDICATIONS