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Patient Registration

Gerald Middleton DDS

4234 Riverwalk Parkway, Suite 100,
Riverside, CA 92505
(951) 688-3442

Patient Details( * mandatory to fill )
Contact Information( * mandatory to fill )
Responsible Party's Information( * mandatory to fill )
Emergency Contact Information( * mandatory to fill )
INSURANCE( * mandatory to fill )

 

Secondary Insurance (skip to next page if no secondary insurance)

Medical History( * mandatory to fill )

SELECT APPROPRIATE ANSWER

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The practice of dentistry involves treating the whole person. If the dentist determines that there may be a potentially medically compromised situation, medical consultation may be needed prior to commencement of dental treatment.

 

I authorize the dentist to contact my physician.

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Have you ever had or do you have any of the following?

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Are you allergic to or have you had a reaction to any of the following?

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ARE YOU TAKING OR HAVE YOU TAKEN ANY OF THE FOLLOWING IN THE LAST THREE MONTHS?

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ALL PATIENTS

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WOMEN ONLY (Select Yes or No for each)

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Authorization

I certify that I have read and understand the above. To the best of my knowledge, I have answered every question completely and accurately. I understand the importance of a truthful medical and dental history and that my dentist and his/her staff will rely on this information for treating me. I will inform my dentist of any change in my health and/or medication. Further, I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form. 

I authorize the diagnosis of my dental health by means of radiographs, study models, photographs, or other diagnostic aids deemed appropriate.

I authorize the dentist to release any information including the diagnosis and records of treatment or examination for myself and my dependent(s) to third-party insurance carriers, payors, and/or healthcare practitioners.

I consent and agree to be financially responsible for payment of all services rendered on my behalf or on behalf of my dependent(s).

I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction.

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Dental History( * mandatory to fill )

At-Home Oral Hygiene Care 

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Select Appropriate Answer (Leave blank if you do not understand the questions) 

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  •  I confirm that all questions have been answered

 

Patient Signature

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Parent/Guardian Signature

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