Online Patient Form Patient Registration Policy Holder Responsible Party Person responsible for account. They must be present at appointment to show ID Responsible Party is also a policy holder for Patient Primary Insurance Policy Holder Secondary Insurance Policy Holder Patient Information Sex: Male Female Marital Status: Married Single Divorced Separated Widowed I would like to receive correspondences via e-mail. Employment Status: Full-Time Part-Time Retired Student Status: Full-Time Part-Time Primary Insurance Information Primary Insurance Information Relationship to Insured: Self Spouse Child Other Secondary Insurance Information Relationship to Insured: Self Spouse Child Other 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 medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions. Are you under a physician's care now? Yes No Have you ever been hospitalized or had a major operation? Yes No Have you ever had a serious head or neck injury? Yes No Are you taking any medications, pills, or drugs? Yes No Do you take, or have you taken, Phen-Fen or Redux? Yes No Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? Yes No Are you on a special diet? Yes No Pregnant/Trying to get pregnant? Yes Nursing? Yes Do you use tabacco? Yes No Taking oral contaceptives? Yes Do you use controlled substances? Yes No Are you allergic to any of the following? Aspirin Penicillin Codeint Acrylic Metal Latex Local Anestetics Sulga Drugs Other Do you have, or have you had, any of the following? AIDS/HIV Positive Chest Pains Frequent Headaches Hypoglycemia Rheumatic Fever Alzheimer's Disease Cold Sores/Fever Genital Herpes Irregular Heartbeat Rheumatism Anaphylaxis Heart Disorder Glaucoma Kidney Problems Scarlet Fever Anemia Convulsions Hay Feve Leukemia Shingles Angina Cortisone Medicine Heart Attack/Failure Liver Disease Sinus Trouble Arthritis/Gout Diabetes Heart Murmur Low Blood Pressure Spina Bifida Artificial Heart Valve Drug Addiction Heart Pacemaker Lung Disease Stomach Disease Artificial Joint Easily Winded Heart Trouble Mitral Valve Prolapse Stroke Asthma Emphysema Hemophilia Osteoporosis Swelling of Limbs Blood Disease Epilepsy or Seizures Hepatitis A Pain in Jaw Joints Thyroid Disease Blood Transfusion Excessive Bleeding Hepatitis B or C Parathyroid Disease Tonsillitis Breathing Problem Excessive Thirst Herpes Psychiatric Care Tumors or Growths Bruise Easily Dizziness High Blood Pressure Radiation Treatment Ulcers Cancer Frequesnt Cough High Cholesterol Recent Weight Loss Cenereal Disease Chemotherapy Frequent Diarrhea Hives or Rash Renal Dialysis Yellow Jaundice Have you ever had any serious illness not listed above? Yes No Comments: To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status. SIGNATURE OF PATIENT, PARENT, or GUARDIAN Todays Date Submit Form Your request has been sent -- we will be in contact with you shortly. There was an error! Please phone our office.
