PATIENT REGISTRATION INFORMATION DENTAL INSURANCE INFORMATION. Title:! Mr.! Mrs.! Ms.! Miss! Dr. Patient: Last Name: First Name: Middle:
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1 Title:! Mr.! Mrs.! Ms.! Miss! Dr. PATIENT REGISTRATION INFORMATION Patient: Last Name: First Name: Middle: Wish to be called: D.O.B.: / / Age: Sex:!Male! Female SSN: - - Marital Status:! Single!Married! Widowed! Divorced! Separated Address: Apt.#: City: State: Zip: Home Phone: ( ) - - Cell Phone: ( ) Employment Status:! Full Time! Part Time! Retired Student Status:! Full Time! Part Time! Employer /! School at: Employer/School Phone#: ( ) - - Ext: Employer/School Address: How did you hear about us?! Google Search! Facebook! Website! Saw our Sign! Insurance List! Someone you know! Other Emergency Contact Details: Contact Name: Relationship: Home Phone: ( ) - - Cell Phone: ( ) - - Primary Insurance Information: Insured s Name: Secondary Insurance Information: DENTAL INSURANCE INFORMATION Insured s Name: Relationship to Patient:! Self! Spouse! Child! Other Relationship to Patient:! Self! Spouse! Child! Other If Other: D.O.B.: / / SSN: - - Employer: Address: City: State: Zip: Group#: ID#: If Other: D.O.B.: / / SSN: - - Employer: Address: City: State: Zip: Group#: ID#:
2 PATIENT DENTAL INFORMATION Patient Name: Date of Last Dental Visit Date of Last Cleaning Date of Last Dental X-Rays Do you have areas in your mouth that concerns you now?!upper Left!Upper Right!Lower Left!Lower Right Are any of your teeth sensitive to:!hot!cold!sweets!pressure Have you ever had: Orthodontic treatment Periodontal (gum) treatment Oral Surgery Worn a bite plate (night guard) Have you noticed: Loosening of your teeth Food catching between your teeth Pain/swelling of your gums Bad breath Have you experienced: Clicking of the jaw Pain (joint, ear, side of face) Difficulty in opening/closing Difficulty chewing Do you, or Have you ever been told that you: Clench or grind your teeth Bite your lips or cheeks Breathe through your mouth while asleep What s most important to you in a relationship with your dentist? What are your expectations of our office? What did you like best about your previous dentist? Why did you decide to change your dentist? If you could waive a magic wand and change your teeth or smile, what would you change?
3 PATIENT MEDICAL HISTORY Name of your Primary care physician: Phone# Preferred Pharmacy Name, Location: Phone# List any serious illnesses, surgeries or hospitalizations: List any Prescription or Over the counter Medicine, including Vitamins, Natural or Herbal preparations and diet supplements: List, if you take, any blood thinners:! None!Aspirin! Plavix! Coumadin! Other Were you treated or are you scheduled to begin treatment with medications like Fosamax, Actonel, or Boniva for treatment of osteoporosis OR intravenous bisphosphonates (Aredia or Zometa) for bone pain, hypercalcemia or skeletal complications resulting from Paget s disease, multiple myeloma or metastatic cancer? Do you use any controlled substances? If Yes, List: Do you use tobacco? History of joint replacement: If Yes, date of replacement: Has a Physician or dentist recommended taking antibiotics prior to your dental treatment? Are you allergic to any of the following?! Local Anesthetics! Penicillin/other antibiotics! Acrylic! Metals! Aspirin! Sulfa drugs! Codeine/other narcotics! Latex! Other: Please specify Women: Are you Pregnant? Nursing Taking Birth control pills Do you currently have, or have you had any of the following?! AIDS / HIV! Cancer (Type)! Heart Attack! Mitral Valve Prolapse! Alzheimer s! Chemo Therapy! Heart Murmur! Neurological Disorder! Anaphylaxis! Cold Sores / Fever Blisters! Heart trouble / Disease! Pace Maker! Angina/Chest Pain! Cortisone Medicine! Hemophilia! Persistent Swollen Glands in the neck! Arteriosclerosis! Decreased Blood Sugar! Hepatitis A! Psychiatric Care! Arthritis! Diabetes Type I or II! Hepatitis B or C! Radiation Treatment! Artificial Heart Valve! Eating Disorder! Herpes! Rapid Weight Loss! Artificial Joint! Epilepsy / Seizure! High Blood Pressure! Renal Dialysis! Asthma! Fainting Spells / Dizziness! Hives / Rash! Sexually Transmitted Disease! Autoimmune Disease! Frequent Headaches! Kidney Problems! Shingles! Blood Disease! Gastrointestinal Disease! Leukemia! Sinus Trouble! Blood Transfusion! GE Reflux / Persistent Heartburn! Liver Disease! Sleep Disorder! Breathing Problems! Genital Herpes! Low Blood Pressure! Stroke! Bruise Easily! Glaucoma! Lung Disease! Systemic Lupus Erythematosus Have you ever had any serious illness not listed above? If Yes, please explain:!yes!no 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 patients ) health. It is my responsibility to inform the dental office of any changes in medical status. Signature of Patient/Parent/Guardian Date Printed Name
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Sorina Ratchford DDS 747 Bernardo Ave. T:(805) Morro Bay Family Dentistry Morro Bay, CA F:(805) Page 1 /4
Morro Bay Family Dentistry 747 Bernardo Ave. Morro Bay, CA 93442 (805) 772-8585 Date: Patient Information Name Birth date SS# Driver's License # Expiration Address City State Zip Home Phone Cell Phone
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GIDEON G. LEWIS, M.D. Date: LAST Name: FIRST Name: MIDDLE Initial: Address: City: State: Zip Code: Date of birth: / / Social Security #: - - Sex: M F Marital Status (Circle): Single Married Divorced Widowed
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SLEEP SCREENING QUESTIONNAIRE Please answer each question accurately and to the best of your knowledge, to help us obtain an accurate picture of your health and sleep issues, only this way will we be able
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REGISTRATION AND HEALTH HISTORY Name: Social Security #: Name we should call you: Date of Birth: Home Phone #: Cell #: E-mail Address: Address: Employed By: Position: Work Phone# Marital Status: Spouse
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Patient Information Please Print NAME Referred to us by of birth Age Single Married Divorced Widowed Separated Minor (under 18) Full time student Parent/Guardian if minor Address Home ph City State Zip
More informationCreating and maintaining your oral health is our primary goal. Thank you for giving us the opportunity to pursue this goal with you.
Welcome to our wonderful family of patients. Thank you for selecting us as your personal dental care team. We will strive to make your relationship with us a pleasant and rewarding one. A firm foundation
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Lake Forest Dental We are pleased to welcome you to our practice. Please take a few minutes to fill out this form completely. If you have any questions we ll be glad to help you. We look forward to working
More informationLake Forest Dental. Patient Information
Lake Forest Dental We are pleased to welcome you to our practice. Please take a few minutes to fill out this form completely. If you have any questions we ll be glad to help you. We look forward to working
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Account # PATIENT REGISTRATION PATIENT INFORMATION: Name M.I. Sex: o Male o Female Home Address Social Security # Birthdate Age Home Phone ( ) Mobile Phone ( ) Name of General Dentist E-Mail Address Years
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