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Patient Registration Form

Alaska Smiles

1000 E. Dimond Blvd, Suite 210,
Anchorage, AK 99515
(907) 278-6684

Patient Details( * mandatory to fill )
Contact Information( * mandatory to fill )
  •  Google Search
  •  Google Maps
  •  Bing
  •  Facebook
  •  Instagram
  •  Yelp
  •  Insurance Co.
  •  Website
Responsible Party's Information( * mandatory to fill )
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(Your IP Address : IP:34.238.190.122 )
Primary Insurance Details( * mandatory to fill )
Secondary Insurance Details( * mandatory to fill )
Authorisation( * mandatory to fill )

I authorize the use of any information necessary to process my insurance. I also authorize my insurance company(s) to issue the dental benefits of my plan directly to this office.

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(Your IP Address : IP:34.238.190.122 )
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(Your IP Address : IP:34.238.190.122 )
DENTAL HISTORY( * mandatory to fill )
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Sensitivity(hot, cold, sweet)
  •  Headaches, neck or jaw joint pain
  •  Mouth ulcers or cold sores
  •  Grinding or clenching
  •  Bleeding swollen or irritated gums
  •  Loose, chipped or shifting teeth
  •  Whiten your teeth
  •  Straighten your teeth
  •  Close Spaces
  •  Replace silver-metal fillings with tooth colored fillings
  •  Repair chipped teeth
  •  Replace missing teeth
  •  Replace old crowns that don’t match
  •  Have a smile makeover
  •  Full or partial dentures
  •  Braces
  •  Periodontal gum treatments
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

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  •  10
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MEDICAL HISTORY( * mandatory to fill )
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
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  •  No
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  •  No

ALLERGIES

  •  Aspirin
  •  Codeine
  •  Erythromycin
  •  Latex
  •  Local Anesthetic
  •  Penicillin
  •  Other
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(Your IP Address : IP:34.238.190.122 )
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