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Patient Registration Form Adult

State Street Smiles

405 Main Street,
Hackensack, NJ 07601
(201) 487-7030

Patient Information( * mandatory to fill )

Thank you for selecting our dental healthcare team! We will strive to provide you with the best possible dental care. To help us meet all your dental healthcare needs, please fill out this form completely. If you have any questions or need assistance, please ask us we will be happy to help.

Dental Insurance Information( * mandatory to fill )

(Please provide information for insured party)

  •  Yes
  •  No
Patient Medical History( * mandatory to fill )
  •  Yes
  •  No
  •  Yes
  •  No
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  •  No
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  •  No
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  •  Yes
  •  No
  •  Yes
  •  No
  •  Nitrous oxide/laughing gas
  •  Penicillin
  •  Codeine or other narcotics
  •  Iodine
  •  Latex
  •  Other Antibiotics
  •  Barbiturates
  •  Aspirin
  •  Local Anesthetics (i.e. Novocaine/epinephrine)
  •  Sulfa Drugs
  •  Sedatives
  •  Other

Women Only

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

(Note: Antibiotics counteract the effect of birth control pills. Please consult your physician.)

Do you have or have you had any of the following?

  •  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
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
Patient Dental History( * mandatory to fill )
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

Have you ever experienced any of the following problems in your jaw?

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

Consent, Authorization, and Release

I certify that I have read and understand the information to the best of my knowledge. The questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. 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 dentist or staff to perform all dental services that I or my child/dependent may need. I authorize the dentist to release any information including the diagnosis and the record 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 directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that it is my responsibility to know the terms of my dental insurance contract (i.e. How often my insurance carrier will pay for exams and cleanings). This consent shall remain in full force and in effect until canceled by either party.

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ACKNOWLEDGEMEMT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES( * mandatory to fill )

I

have received a copy of this office Notice of Privacy Practices.

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