Patient Registration Forms - ProSites, Inc.



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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