Patient Form

REGISTRATION FORM

(Please Print)
* Please be sure to fill out ALL areas of registration form,  especially underlined areas.

PATIENT INFORMATION

Patient’s last name: First: Middle: Title: (please circle)  Mr.         Mrs     Ms.

Miss.       Dr

Is this your legal name? If not, what is your legal name? (Former name): Birth date: Age: Sex:
 Yes  No        /          / M  F
Street address: Mobile Phone no: Home phone no:
P.O. box: Suburb: State: Post Code:
Email Address: 

 

Occupation: Employer: Employer phone no.:
Work  address: (       )

 

Chose clinic because/Referred to clinic by (please check one box or comment):
 Family  Friend  Close to home/work  Internet  Other? ____________________________
Other family members seen here:

INSURANCE INFORMATION

Do you have Private Health Insurance?    Y   N     Insurance Company:

 (Please give your insurance card to the receptionist.)

Person responsible for bill: Birth date: Address (if different): Contact phone no.:
       /         / (       )

MEDICAL QUESTIONS

Rheumatic Fever               Heart Conditions             High Blood Pressure               Stroke              Asthma             Diabetes
Thyroid Problems         Tuberculosis      Epilepsy      Bone Disorders or Diseases      Fainting/Dizzy Spells        Excessive Bleeding
Hepatitis A/B/C/E         A.I.D.S/HIV  Virus             Would you like to discuss these questions in private with the dentist?  Y   N
Family History of Heart Disease, Diabetes or Stroke?                                                                                                                        Y   N
Are you allergic to any Medications: i.e. (penicillin/aspirin)?                                                                                                          Y   N
Do you have any allergies?                                                                                                                                                                        Y   N
Are you taking any medications? (Please specify)                                                                                                                                Y   N
Have you ever had an operation? (Please specify)                                                                                                                               Y  N
Do you have: an artificial hip, heart valve or any other prosthetic implant?                                                                                  Y   N
Have you ever had Botox?                                                                                                                                                                          Y   N
Have you ever had Dermal Filler?                                                                                                                                                             Y   N
Females: Are you pregnant?    Y   N     Comments:
Any other medical conditions:
Are you a smoker? Y    N     If yes, how many a day?
Name/address/phone number of Medical Practitioner:

 

IN CASE OF EMERGENCY

Name of local friend or relative : Relationship to patient: Home phone no.: Work phone no.:
(      ) (      )
The above information is true to the best of my knowledge, and I understand that failure to make a full disclosure might place ME at undue medical risk.  I understand that notes, radiographs (x-rays) or models relating to my treatment may need to be sent to other dental practitioners to aid them in my treatment and consent to this. I also give my permission for the practice to use the above contact details to send me appointment and check up reminders.

I authorize my insurance benefits to be paid directly to the Provider. I understand that I am financially responsible for any balance. I also authorize Hadfield Dental Group or insurance company to release any information required to process my claims.

I understand that I will be responsible for any debt collection fees that might incur due to my lack of finalizing my account by the requested date.

  Patient/Guardian Signature:    

Date: