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Patient Information

REGISTRATION AND DENTAL HISTORY

1.PATIENT INFORMATION

Last Name
First Name
Middle Initial
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F
Married
Widowed
Single
Minor
Separated
Divorced
Partnered for years

2.DENTAL INSURANCE

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I certify that I, and/or my dependent(s), have insurance coverage wi and we assign directly to the Name of the Insurance Company(s)
Dr.all insurance benefits, if Patient Employer/School Or.any, otherwise payable to me for services rendered. | understand that | am financially responsible for all charges whether or not paid by insurance. | authorize the use of my signature on all insurance submissions..

The above-named dentist may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

Signature of Patient, Parent, Guardian or Personal Representative
Please print name of Patient, Parent, Guardian or Personal Representative
Date
Relationship to patient

3.Phone Numbers

IN CASE OF EMERGENCY, CONTACT (Specify someone who does not live in your household.)

4.Dental History

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5. HEALTH HISTORY

Physician's NameDate of last visit Have you ever used a bisphosphonate medication? Common brand names are Fosamax, Actonel, Atelvia, Didronel, Boniva.YesNo
Have you ever taken any of the group of drugs collectively referred to as “fen-phen?” These include combinations of lonimin, Adipex, Fastin (brand names of ph entermine), Pondimin (fenfluramine) and Redux (dexfenfluramine).YesNo
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Medications
List any medications you are currently taking and the correlating diagnosis :
Allergies
Aspirin
Barbiturates (Sleeping pills)
Codeine
Lodina
Latex
Local Anesthetic
Penicilin
Sulfa
Others

6.Updates (To be filled in at future appointments)

Has there been any change in your health since your last dental appointment? :YesNo