Registration

Please fill out the patient information below.

First Name: Last Name:
Birthdate : Age : Marital Status : Social Security Number : - -
Home Address :


,
Home Phone : - - Cell Phone : - - Pager : - -
Work Phone : - - E-Mail Address :
Employer : Occupation :

Person Responsible for Account : (check this box if the patient is the person responsible for the account)
First Name: Last Name: Relationship :
Social Security Number : - - Birthdate : Home Phone : - -
Home Address:


,
Employer : Work Phone : - -
Do you have Dental Insurance? No Yes With Whom?

In case of emergency notify:
First Name: Last Name: Relationship :
Address (if different) :


,
Home Phone : - -

Are you currently having dental problems? Yes No
What are your concerns? Check as many as applicable:
Pain Avoidance
Appearance
Losing Teeth
Gum/Periodontal Disease
Cavities
Oral Cancer
Wasting/Exceeding Dental Insurance Limits
Your General Health
Routine Checkup
Cleaning
Other:

MEDICAL / DENTAL HISTORY (Answers confidential and for our records only)

1. Has there been any change in your general health in the past 2 years?   No Yes
If so, what?

2. Date of your last physical examination:

3. Are you presently under the care of a physician?   No Yes
If so, for what reason?
4. Physician's Name:  
Physician's Address:


,
Physician's Phone: - -

5. Have you been hospitalized in the past 2 years?   No Yes
If so, for why?
Were there any complications?

6. Are you presently taking any medications or pills?   No Yes
If yes, what are the medications and what are they for?

7. Are you sensitive or allergic to any drugs or medications?   No Yes
If yes, to what? Describe your reaction.

8. Is the patient allergic to anything other than medicine? (E.g. latex or metals)?   No Yes
If so, what?

9. When you walk up stairs or take a walk, do you ever have to stop because of shortness of breath, chest pain, or because you become very tired?   No Yes

10. Have you unintentionally lost or gained more than 10 pounds in the past year?   No Yes

11. Has your physician ever said you had cancer or a tumor?   No Yes

12. Have you had surgery, radiation or drug treatment for a tumor, growth, or other condition of your head or neck?   No Yes

13. Does your job bring you Into contact with blood, blood products or needles?   No Yes

14. Have you ever had any trouble associated with previous dental treatment?   No Yes
If so, for what?

15. Have you ever had excessive bleeding after dental treatment requiring special care?   No Yes

16. Are you taking blood thinners or daily aspirin therapy?   No Yes

17. Have you ever had an undesirable reaction to anesthetic (either local or general)? For example, Novocaine, xylocaine or gas?   No Yes

18. CHECK ANY CONDITION THAT YOU NOW HAVE OR HAVE HAD IN THE PAST
Heart Disease / Attack
Heart Failure
Angina Pectoris (Chest Pain)
High Blood Pressure
Heart Murmur
Rheumatic Fever
Mitral Valve Prolapse
Cardiac Pacemaker
Artificial Heart Valve
Damaged Heart Valves
Heart Surgery
Artificial Joint / Prosthesis
Cortisone / Steroid Medicine
Anemia
Sickle Cell Disease
Blood Transfusion
I.V. Drug Use/Abuse
Hemophilia
HIV Positive (AIDS Antibody)
AIDS
Ulcers
Glaucoma
Kidney / Bladder Disease
Enlarged Glands or Lymph Nodes
Arthritis
Hay Fever / Allergy
Sinus Trouble
Diabetes (Blood Sugar)
Venereal Disease
Asthma
Tuberculosis
Pneumonia (Lung Infection)
Emphysema
Chronic Cough
Hepatitis A, B or C
Liver Disease
Yellow Jaundice
Radiation
Chemotherapy
Stroke
Epilepsy or Seizures
Nervousness
Psychiatric Treatment

Women (Check this box if you are not a woman )

19. Are you pregnant?   No Yes

20. Are you nursing?   No Yes

21. Are you taking the birth control pill?   No Yes

22. Are you taking hormone replacement therapy?   No Yes

23. Do you anticipate becoming pregnant?   No Yes

24. Do you have problems with your period?   No Yes

INSURANCE

I authorize the release of any information relating to my claim.

I authorize payment directly to Dr. Randall.

I understand that all fees not paid by insurance are my responsibility.

Who can we thank for referring you to our office?

Can we confirm your dental appointments at your place of employment?   No Yes
If not, what is the best time to contact you at home?

I Understand That Payment Is Due At Time Of Service.

I Will Pay By: CASH CREDIT CARD

I understand that where appropriate, credit bureau reports may be obtained.

 
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