Infinity registration forms

Given Name

Marital Status

Surname

Pronunciation

Prefer to be called

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Number

Please enter a valid phone number.Format: (000) 000-0000.

Work Phone

Please enter a valid phone number.Format: (000) 000-0000.

Date of Birth

Date

Cell Phone

Please enter a valid phone number.Format: (000) 000-0000.

Other

Please enter a valid phone number.Format: (000) 000-0000.

Employer/School

Occupation

Email Address

Contact Method

Who may we thank for referring you to this office?

Family Physician

Phone

Please enter a valid phone number.Format: (000) 000-0000.

In Case of Emergency Notify

Relation

Phone

Please enter a valid phone number.Format: (000) 000-0000.

Person responsible for this account:

Name

(Last)(First)(Initial)Relation

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.

Subscriber

Date of Birth

Date

Relation:

Other

Subscriber l.D.

Insurance Co

Policy/Plan #

Division/Sect. #

Are you Familiar with Your Plan Details?

Subscriber

Date of Birth

Date

Relation:

Other

Subscriber l.D.

Insurance Co

Policy/Plan #

Division/Sect. #

Are you Familiar with Your Plan Details?

Have you ever had a serious illness requiring hospitalization or extensive medical care?

Please Specify:

Are you presently under the care of a physician?

If so, please explain:

Have you had a medical examination in the last year?

Do you use any prescription or non-prescription drugs regularly?

Please specify:

Do you have any allergic conditions: e.g., hay fever, skin rash, food allergies, metal, latex?

Do any allergic reactions result in headaches, shortness of breath, chest constriction, nausea?

Please specify:

Have you been hospitalized in the last 5 years?

Please specify:

Have you ever experienced any unusual reaction to any of the following?

Have you been warned against taking any drug or medication?

Do you bruise easily or bleed abnormally?

Do you require pre-medication for dental treatment?

Have you ever had any organ implants or medical implants?

Have you ever fainted?

Do your ankles swell?

Do you experience shortness of breath or chest pain when taking a walk or climbing stairs?

Do you have frequent headaches?

Do you have A.I.D.S. or have you ever tested positive for H.I.V.?

Do you have any of the following? Please check any that apply

Have you had any injury, surgery or x-ray therapy to your face or jaws?

Do you have any disease, condition, or problem that you think the doctor should know about

Are you pregnant or suspect you might be?

Are you taking birth control pills?

Are you nursing?

Reason for today's visit

Other

Are you presently having dental pain?

Is there a dental problem you would like to take care of as soon as possible?

Please specify:

How frequently do you see your dentist?

Other

Last dental visit:

Last cleaning

Full mouth series of x-rays:

How often do you brush your teeth?

Floss?

Do your gums bleed easily?

Are your teeth sensitive to:

Do you feel you have bad breath at times?

Have you ever had jaw joint surgery?

Do you have pain in your jaw joints or suffer from migraine headaches?

Does any part of your mouth hurt when clenched?

Does your jaw crack or pop when opened widely?

Have you had:

Do you grind or clench your teeth during the day or night?

Do you smoke? Number per day:

Do you or does any family member have a problem with snoring?

Have you ever experienced any growths or sore spots in your mouth? If so, where?

Previous problems with dental treatment? Specify:

Are you satisfied with the appearance of your teeth?

Please specify:

Other Dental Concerns:

Privacy Act Notification: I have been informed of the privacy policy of this office and understand that all information I have supplied will be used and disclosed as set out within this office policy.

Office Policy: Your appointment time will be reserved for you. If you are unable to keep the appointment we will require 48 hours notice.

Patient Release: I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my medical-dental history. I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I also understand that consultation with my medical doctor may be required, and I consent to my physician being contacted as necessary. I understand that responsibility for payment for the dental services provided for myself and my dependent’s is mine, and I will assume responsibility for fees associated with these services.

Signature

Date

Reviewing Dentist

PATIENT REGISTRATION

Primary Insurance

Secondary Insurance

MEDICAL HISTORY

WOMEN ONLY -

DENTAL HISTORY