Patient Registration Form Patient Details

Patient Registration Form Contact Information

Patient Registration Form Emergency Contact Information

Patient Registration Form

Patient Registration Form Medical History

Since periodontal disease is produced by a combination of many complex elements, it is necessary to resolve every possible contributing factor. The success of therapy is most dependent upon this. Though some of the following questions may seem unrelated to your gum condition, they are associated with proper management of your oral health. Your answers are for our records only and will be considered confidential.

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

5. Are you allergic to any of the following?

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

7. Indicate which of the following you have had or have at the present:

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
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  •  Yes
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  •  Yes
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  •  Yes
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  •  Yes
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  •  Yes
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  •  Yes
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  •  Yes
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  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
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  •  Yes
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  •  Yes
  •  No
  •  Yes
  •  No
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  •  Yes
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  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
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  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
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  •  Yes
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  •  No

9. In order to prevent complications associated with heart disease, heart murmur, artificial heart valves or artificial joint replacement. it is often necessary to take antibiotics prior to any dental appointment. Please contact your physician or our office before your first appointment if you have any questions regarding premedication.

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

Women:

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

Patient Registration Form

I certify the above to be true.

CONSENT

The undersigned hereby authorizes Doctors to perform all necessary procedures deemed appropriate to make a thorough diagnosis of the patients dental or oral-facial needs including x-rays, study models, photographs. medications and the use of local anesthetic agents. I understand that responsibility for payment of dental services provided in this office for myself or my dependents is mine. due and payable at the time services are rendered., unless financial arrangements have been made. I further understand that a 1 1/2 percentage finance
charge (18" annually) will be added to any balance over 90 days. In the event of default, I promise to pay legal interest on the indebtedness, together with such collection costs and reasonable attorney fees as may require to effect collection of this note.

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