Oak Creek Dental Care-Patient Registration Form

Patient Registration Form Patient Details

First Name*

Last Name*

Middle Initilal

Title

Preferred Name

Gender*

Family Status*

Date of Birth*

Previous Visit

Address*

City*

State*

Zip*

Social Security Number*

How did you hear about our office?

Have you been advised that you must take an antibiotic prior to dental treatment?

Yes
No

lf yes, please list what for?

Patient Registration Form Contact Information

Email Address

Home Phone

Mobile Phone*

Work Phone

Ext

Best time to call

We now offer patient appointment reminders via text or email. Please select your preference for receiving your appointment reminders

Email Reminder
Text Reminder

Patient Registration Form Medical History

Do you or have you experienced the following?

Allergies/Hayfever

Yes
No

Arthritis

Yes
No

Aspirin Allergy

Yes
No

Barbiturates

Yes
No

Clindamycin Allergy

Yes
No

Coumadin

Yes
No

Dizziness/Fainting

Yes
No

Excessive Bleeding

Yes
No

Heart Attack

Yes
No

Heart Murmur

Yes
No

HIV

Yes
No

Irregular Heartbeat

Yes
No

Kidney Disease

Yes
No

Local Anesthetic

Yes
No

Mitral valve prolapse

Yes
No

Organ Transplant

Yes
No

Penicillin Allergy

Yes
No

Radiation Treatment

Yes
No

Sedatives

Yes
No

Sleep Apnea

Yes
No

Thyroid Problems

Yes
No

Venereal Disease

Yes
No

Anemia

Yes
No

Artificial Joints

Yes
No

Asthma

Yes
No

Blood Disease/Disorder

Yes
No

Codeine Allergy

Yes
No

Dementia

Yes
No

Emphysema

Yes
No

Glaucoma

Yes
No

Heart Disease

Yes
No

Hepatitis

Yes
No

Immune Disorder

Yes
No

Jaundice

Yes
No

Latex Allergy

Yes
No

Low Blood Pressure

Yes
No

Multiple Sclerosis

Yes
No

Osteoporosis

Yes
No

Pregnancy

Yes
No

Respiratory Problems

Yes
No

Seizures

Yes
No

Stroke

Yes
No

Tuberculosis

Yes
No

Angina

Yes
No

Artificial Valve

Yes
No

Autism

Yes
No

Cancer

Yes
No

COPD

Yes
No

Diabetes

Yes
No

Epilepsy

Yes
No

Headaches/Migraines

Yes
No

Heart Failure

Yes
No

High Blood Pressure

Yes
No

Intestinal Problems

Yes
No

Joint Replacement

Yes
No

Liver Disease

Yes
No

Mental Disorders

Yes
No

Nervous Disorders

Yes
No

Pacemaker

Yes
No

Psychosis/Mania

Yes
No

Rheumatism

Yes
No

Sinus Problems

Yes
No

Sulfa Allergy

Yes
No

Tumors

Yes
No

Please select any of the following that apply

Pregnant

Yes
No

Nursing

Yes
No

Taking birth control

Yes
No

Tobacco use

Yes
No

Use or abuse recreational drugs

Yes
No

Patient Registration Form

Please describe your current medical treatment or any other medical condition/medical allergies not listed

Please list any/all medication(s) you are taking, including non-prescription medication(s)

Please list any surgeries you have had

Known Allergies

Emergency contact name*

Phone Number*

Medical Doctor*

Phone Number*

I certify that I have read and understand the information given to me. I understand that providing incorrect information can be dangerous to my health; the questions have been accurately answered. I authorize the dentist to release any information, including diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payers and/or health practitioners. I authorize and request my insurance company to pay insurance benefits otherwise payable to me, directly to the dentist or dental group. I understand my dental insurance carrier may pay less than the actual bill of services. I agree to be responsible for payment of all services rendered on my behalf or my dependents (including broken appointment fees, late fees, collection agency, and/or attorney fees). I acknowledge that I have received and read a copy of the privacy practices and welcome policies.

SIGNATURE (Signature)*

(Please click below to draw/upload sign)

(Your IP Address :IP:3.232.96.22 )

Patient Registration Form Broken Appointment Policy

Broken Appointment policy

A 48 hour advance notice is requested if you are unable to keep an appointment. A charge of $61 per hour will be applied for appointments broken without a 48 hour notice.

I,

have read and understand Oak Creek Dental Care's broken appointment policy.

Insurance

As a courtesy, Oak Creek Dental Care will file your insurance for you. The patient portion quoted to you is simply an estimate based on the information we have gathered from your insurance carrier. Oak Creek Dental Care does not accept responsibility for lack of insurance coverage or for anything your insurance does not pay.

I,

have read and understand Oak Creek Dental Care's insurance disclaimer and understand that it is ultimately my responsibility to know my insurance benefits.

SIGNATURE (Patient Signature)*