Patient Registration and Health History Form
* required field

Patient Registration

Sex


Emergency Contact Information


IF PATIENT IS MINOR OR NOT A RESPONSIBLE PARTY

Sex


AVAILABLE DENTAL INSURANCE


Primary Carrier


Secondary Carrier


Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire 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?

Have you ever had a serious head or neck injury
Are you taking any medication, pills, or drugs?

Do you take, or have you taken, Phen-Fen or Redux?

Have you ever taken Fosamax, Boniva, Actonel or any other medication containing bisphosphonates?

Are you on a special diet?

Do you use tobacco?

Do you use controlled substances?

Pregnant/Trying to get pregnant? (Women Only)

Taking oral contraceptives? (Women Only)

Nursing (Women Only)

Are you allergic to any of the following?

Please Check all that apply

Have you ever had any serious illness not listed above?

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 health (or the health of the patient). It is my responsibility to inform the dental office of any changes in medical status.



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