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Patient Registration Form
4K Dentistry
21434 Provincial Blvd,
Katy, TX 77450
2813984369
Patient Details
( * mandatory to fill )
First Name
*
Last Name
*
Middle Name
Date Of Birth
*
Address
*
City
*
State
*
Select
ALABAMA
ALASKA
AMERICAN SAMOA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLUMBIA
FEDERATED STATES OF MICRONESIA
FLORIDA
GEORGIA
GUAM
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARSHALL ISLANDS
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
NORTHERN MARIANA ISLANDS
OHIO
OKLAHOMA
OREGON
PALAU
PENNSYLVANIA
PUERTO RICO
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGIN ISLANDS
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
Zip
*
Gender
*
Select
Male
Female
Marital Status
*
Select
Single
Married
Widowed
Divorced
Seperated
Social Security Number
*
Driving License Number
Contact Information
( * mandatory to fill )
Email
*
Home Phone Number
Cell Phone Number
*
Work Phone Number
Work Extension Number
Responsible Party's Information
( * mandatory to fill )
Address
*
City
*
State
*
Select
ALABAMA
ALASKA
AMERICAN SAMOA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLUMBIA
FEDERATED STATES OF MICRONESIA
FLORIDA
GEORGIA
GUAM
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARSHALL ISLANDS
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
NORTHERN MARIANA ISLANDS
OHIO
OKLAHOMA
OREGON
PALAU
PENNSYLVANIA
PUERTO RICO
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGIN ISLANDS
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
Zip
*
Home Phone Number
Cell Phone Number
Work Phone Number
Work Extension Number
Social Security Number
Driving License Number
Emergency Contact Information
( * mandatory to fill )
Name
Phone Number
Primary InsuranceDetails
( * mandatory to fill )
Relation To Patient
Select
Self
Parent
Spouse
Other
Name Of Insured
Insured SSN
EmployerName
Insured Person's Address
DOB of Insured
Group Number
REM. BENEFITS
REM. DEDUCT
Insurance Company
Insurance Company Address
Insurance Company City
Insurance Company State
Insurance Company ZipCode
Medical History
( * mandatory to fill )
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 h
Are you under a physician's care now?
yes
no
If Yes,
Have you ever been hospitalized or had a major operation?
yes
no
If Yes,
Have you ever had a serious head or neck injury?
yes
no
If Yes,
Are you taking any medications, pills or drugs?
yes
no
If Yes,
Do you take, or have you taken,phen-fen or Redux
yes
no
If Yes,
Have you ever taken Fosamax, Boniva,actonel or any other medications containing bisphosphonates?
yes
no
If Yes,
Are you on a special diet?
yes
no
Do you use tobacco?
yes
no
Do you use controlled substances?
yes
no
If Yes,
Women, are you?
Pregnant/trying to get pregnant?
Nursing?
Taking oral contraceptives?
Are you allergic to any of the following?
Aspirin
Pencillin
Codeine
Acrylic
metal
Latex
sulfa drugs
Local anesthetics
Other
If Yes,
Do you have, or have you had, any of the following?
AIDS/HIV Positive
Yes
No
Alzheimer's Disease
Yes
No
Anaphylaxis
Yes
No
Anemia
Yes
No
Angina
Yes
No
Arthritis/Gout
Yes
No
Artificial Heart Valves
Yes
No
Artificial Joints
Yes
No
Asthma
Yes
No
Blood Disease
Yes
No
Blood Transfusion
Yes
No
Breathing Problems
Yes
No
Bruise Easily
Yes
No
Cancer
Yes
No
Chemotherapy
Yes
No
Cold sores / Fever blisters
Yes
No
Congenital heart disorder
Yes
No
Convulsion
Yes
No
Cortisone medicine
Yes
No
Diabetes
Yes
No
Difficulty Breathing
Yes
No
Drug Addiction
Yes
No
Easily Winded
Yes
No
Emphysema
Yes
No
Epilepsy or Seizures
Yes
No
Excessive Bleeding
Yes
No
Excessive Thirst
Yes
No
Fainting spells / Dizziness
Yes
No
Frequent Cough
Yes
No
Frequent Diarrhea
Yes
No
Frequent Headaches
Yes
No
Genital Herpes
Yes
No
Glaucoma
Yes
No
Hay Fever
Yes
No
Heart Attack / Failure
Yes
No
Heart Murmer
Yes
No
Heart Pacemaker
Yes
No
Heart Trouble / Disease
Yes
No
Hemophilia
Yes
No
Hepatitis A
Yes
No
Hepatitis B or C
Yes
No
Herpes
Yes
No
High Blood Pressure
Yes
No
High Cholesterol
Yes
No
Hives or Rash
Yes
No
Hypoglycemia
Yes
No
Irregular Heartbeat
Yes
No
Kidney Problem
Yes
No
Leukemia
Yes
No
Liver Disease
Yes
No
Low Blood Pressure
Yes
No
Lung diseases
Yes
No
Mitral Value prolapse
Yes
No
Osteoporosis
Yes
No
Pain in Jaw Joints
Yes
No
Parathyroid Disease
Yes
No
Psychiatric Care
Yes
No
Radiation Treatments
Yes
No
Recent Weight Loss
Yes
No
Renal Dialysis
Yes
No
Rheumatic Fever
Yes
No
Rheumatism
Yes
No
Scarlet Fever
Yes
No
Shingles
Yes
No
Sickle Cell Disease
Yes
No
Sinus Trouble
Yes
No
Spina Bifida
Yes
No
Stomach/Intestinal Disease
Yes
No
Stroke
Yes
No
Swelling of Limbs
Yes
No
Thyroid Disease
Yes
No
Tonsillitis
Yes
No
Tuberculosis
Yes
No
Tumors or Growths
Yes
No
Ulcers
Yes
No
Venereal Disease
Yes
No
Yellow Jaundice
Yes
No
SIGNATURE (Patient Signature)
*
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