Patient Registration Forms

 Date______

Patient ______

Last Name First Name Initial Preferred Name

Home Address / City/ State & Zip Code ______

______

Home Phone #______Work Phone #______

Cell Phone # ______E-mail Address :______

Sex: M___ F___ Date of Birth ______Age ____ Single___Married____Divorced___Widowed____

Patient’s Social Security Number ______-______- ______

Employer:______Occcupation______

Business Address:______

Spouse/ Parent Name:______Spouse/Parent Birthdate:______

Spouse/Parent Employer: ______Occupation ______

Spouse/Parent Social Security Number: ______- ______-______

Who is responsible for this account?______Relationship to patient ______

Name of Dental Insurance Carrier: ______Group #______

In case of an emergency, who should we contact? ______Phone # ______

Whom may we thank for referring you to our practice ? ______

Physician’s Name ______Date of your last physical______

Have you ever had any of the following? Please circle all that apply:

Heart Problems Circulatory Problems

Heart Attack/ Date______Hepatitis, Type:______ Asthma

Heart Murmur Epilepsy Respiratory

Mitro-Valve Prolapse Headaches Problems

Angioplasty Arthritis Pneumonia

Arterial Stent(s) Joint Replacement(s) Sinus Problems

Artificial Heart Valve General Allergies Back Problems

Pace Maker Allergies to Anesthesia Nervousness

Blood Pressure High_____ Low_____ Cancer Dental Phobia

Diabetes Radiation treatment Psychiatric care

Hemophilia Thyroid Problems

Rheumatic Fever Ulcer

Blood Disease/Disorders HIV / AIDS

Stroke Liver Disease

Do you smoke or use chewing tobacco products? YES ______NO______

Do you have any drug allergies or have you ever had an adverse reaction to any medications?

YES______NO______If so, what was the reaction to? ______

Are you taking any medications at this time?______If so what medications? ______

______

MEDICAL HISTORY CONTINUED.....

Are you currently taking Fosamax, Actonel, or any type of blood thinners? YES ______NO______

Have you ever taken any of the group of drugs collectively referred to as “fen-phen?”. These include combinations of Ionimin, Adioex, Fastin, Pondimin, and Redux. YES______NO______

Are you currently under the care of a physician? YES_____ NO_____ If so, for what condition(s)?

______.

If the patient is a child, what is his/her weight?______

(Women) Do you suspect you may be pregnant? YES______NO______

Is there anything else we should know about your medical history? ______

______.

The above information is accurate and complete to the best of my knowledge and is only for the use in my treatment, billing, and processing of insurance benefits for which I am entitled. I will not hold my dentist or any of his staff responsible for any errors or omissions that I may have made in the completion of this form.

Date______Signature______

Assignment & Release

I, the undersigned, have dental insurance with ______

Name of your dental insurance company

and assign directly to ARLINGTON COMFORT DENTAL all benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all changes whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of my signature on all insurance submissions whether manual or electronic.

Date:______Signature ______

Assignment & Release

Minor / Child Consent

I, being the parent of ______do hereby request and authorize the dental staff to perform necessary dental services for my child, including but not limited to x-rays, fluoride , and administration of anesthetics which are deemed advisable by the doctor, whether or not I am present at the actual appointment when treatment is rendered.

Date______Signature of Parent ______

Financial Agreement

I acknowledge that payment is due at the time of treatment, unless other arrangements are made prior to the treatment. I agree that parents/guardians are responsible for all fees and services rendered for treatment of a minor/ child. I accept full responsibility for all charges not covered by insurance.

Date______Signature______

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