New Patient Registration/Medical History

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Adult Registration Form - Medical
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Patient Information

Gender







Primary Phone Number
Secondary Phone Number



PARENT/GUARDIAN INFORMATION (CHILD ONLY)

Relation







Phone Number
Secondary Phone Number


SPOUSE/EMERGENCY CONTACT








INSURANCE INFORMATION
























MISCELLANEOUS INFORMATION

How did you hear about our Practice?

To make sure we address all your concerns -- and answer any questions you may have, please take a minute to mark the areas of you dental care that you would like to discuss with Dr. Siegel and/or Dr. Dolt

How can we help you?


Medical History

Although dental personnel primarily treat the area in and around the mouth, your mouthy is a part of your 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 physicians care now?



Have you ever been hospitalized or had a major operation?
Has your surgeon told you that you are required to pre-medicate before dental appointments?
Have you ever had a serious head or neck injury?
If yes, please explain
Are you taking any medications, pills or drugs?
If yes, please list with the dosage:
Do you take, or have you taken, Phen-Fen or Redux?
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
Are you on a special diet?
Do you smoke or use tobacco?
Women: Are you?
Are you allergic to any of the following?
Do you use controlled substances?

Click if you have or have had any of the following

Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.




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