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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