PATIENT REGISTRATION PLEASE COMPLETE THE FOLLOWING CONFIDENTIAL INFORMATION OA 1 DENTAL INSURANCE 2 CAST NAME FRST wi Pa PREFERS TOBE CALLED BY TNSURANGE COMPANY —— AOORESS ae 35 GROUPRO, appontuent \\ city SAE ‘EIPLOVER ME ‘5FORYOU stanrnene —_/ | HOWE PHONE WO: 3 TNSUREDS NAHE CEL aia DATEOFBRTHY—_[RELATONSHPTOPATEN BRTHOATE | AGE wae] Fence TNSUREDSTO WO, WARD | SNGLE ‘DIVORCED — | wOOWED INSURED SOGIAL SECURITY NO ‘SOCIAL SECURITY WO ie OAT INSURANCE COMPANY a ma GROUPWO 1 me TODRESS a TBPLOVERNAVE See. cry SHE co INSURES WE FORYOUR CHILD starrHene _/ | HOWE PHONENO. DATE GROTH JRELATONSHP TOPATIEN ‘BIRTHOATE [AGE ALE Femie INSUREDSID.WO ‘SOHO GRADE | RSUREDS SOCIAL SECURITY Wo ‘SOCIAL SECURITY NO. a ‘ACCOUNT INFORMATION 4 PERSON FINANCIALLY RESPONSIBLE FOR ACCOUNT nae FELATONSHIPTOATENT | SOA SECURTWO. TDRSS GETTING TO KNOW YOU 3 : 'S ANOTHER MEMBER OF YOUR FAMILY OR RELATIVEA PATENT ar Re 2 room ornce? FOREN a eee YOUWERE REFERRED TOUSEY You a fo ‘oun Fone ADDRESS xR — ov aa a EBLOVERS WANE PERSON TO CONTACT FOR EMERGENCY ADDRESS av PHONE NONBER FROREWS FaRNO TODRESS YOUR SPOUSE cry, a ‘STATE ZP ae nd ‘LOBEST RELATIVENOTLG WIT'VOU SecTON e PRGREWOMBER BUPLOVERS HAE TOBRESS TOORESS aI PRONENO, FARNO. ony sa oe © Pride nsttute —FORMoot (09.02) ‘Please turn over and sign 1800.925.2600 _worw.prideinsitve comCONSENT FOR TREATMENT 1. Inereby authorize doctor or designated staff to take x-rays, study models, photographs, ‘and other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of (name of patient), dental needs, 2. Upen such diagnosis, | authorize doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care. 3. Lagree to the use of anesthetics, sedatives and other medication as necessary. | fully understand that using anesthetic agents embodies certain risks. | understand that | can ask for a compiete recital of any possible complications. 4. | give consent to the doctor's or designated statt's use and disclosure of any oral, written or electronic health records that are individually identifiable as mine for the Purpose of carrying out my treatment, payment and health care operations. | understand that only the minimum amount of information necessary to provide quality care will be used or disclosed and that @ notice fully outlining the protection of my personal health information is available. 5. | agree to be responsible for payment of all services rendered on my behalf or my dependents. | understand that payment is due at the time of service unless other arrangements have been made. In the event payments are not received by agreed upon dates, | understand that a 1-1/2% late charge (18% APR) may be added to my account. If required, | also understand a check of my credit history may be made. Patient’ Signature Date Witness Porent/Responsible Patty's Signature Relationship to PatientMEDICAL HISTORY Patent Aezount No 1. Physician's Name Have you had any medical care within the past WO 288? a. No Desorbe, 2. Have you taken any medication or drugs during the past two years? . No 4 Are you curenty aking any mdcaton, crs pils or herbal remedies, including requ dosages of ep? No tyes, please list name and dosage 4. Have you ever taken prescription medications for weight iss (ct pil)? - : No tyes, did you take any ofthe flowing? (circle if yes) Fen-Phen Pondimen Redux Other tyes to any of the above, did you have a medical exam for heart issues? Yes No 5 Have you ever taken bone os prevention crags suchas Fosamax, Actonel, Boia or ether sir crugs? Yes No 6._ Are you'aware of having an alrgic (or adverse) reaction to any substance or medication? Yes No if yes, please specify 7. Have you been a patent inthe hospital during the past five years? Yes No 8. Indicate which of the following you have had, or have at present. Circle “yes” or “no” to each item. Heart Surgery, Disease, tack)... Yes NO Uber. Yes No Hopattis A BC (crcl)... Yes No Chest Pain Yes No Diabetes = Yes NO Venere DIS58 annem YOS NO Congenital Heart Disease Yes No Thyroid Problems... Yes NO ALDSUHIN.POSHE unum YES NO Heat Mummur Yes No Glaucoma Yes No Cold Sores/Fever Blisters... Yes NO High/Low Blood Pressure... Yes NO Contactenses Yes No Blood Tanstusion Yes No Mitral Vai Prolapse Yes No. Emphysema... Yes NO Hemophilia . Yes No fil Heart VaesPaceaker ..... Yes No Chronic Cough Yes No Sickle Cell Disease Yes No Rheumatic Fever . Yes No Tuberculosis... Yes No BniseEasiy . Yes No ‘ActhrtsRheumatsm Yes No Asthma . Yes No LverDisease/elow Jaundice. Yee No Cortsone Medicine Yes No Hay FeverAlergyives. Yes No Netroogicl Disord num YES NO ‘Swollen Ankles Yes No Latex Seniivty Yes No Epilepsy or Seizures Yes No Stroke Yes No Sinus Trouble Yes No Fainting or Dizzy Spels Yes No Dit Specialties) Yes No. Ratiaton Therapy .. Yes No Nenous/Anvious... Yes No ‘tical Joints tip, knee etc)... Yes No Chemotherapy Yes No PaychistioPsychoiageal Care. Yes No Kidney Touble Yes No Tumors Yes No Ar hare pcs ag me Sere oe] Yes No 10. Do you have or have you had any disease, condton, or problem not iste... Yes No ityes, please ist: 11. Women: Are you pregnant orthnk you could be pregnant? Yes Moths No Nursing? Yes No 412. Doyou use bith conto prescriptions? Yes No understand the above information is necessary to provide me with dental care in a safe and efficient manner. | have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. | wll notify the doctor of any change in my health or medication. monies as Date Patent/Guardian Signature History Review z © Pride Institute FORMO15 (11.07)| DENTAL HISTORY pp Welcome! So that we may provide you with the best possible care please complete both sides of this medicalldental history form. All information is completely confidential. Whats the reason for your visit today? Date of Last Dental Visit Last Dental Cleaning Last Full Mouth X-rays, ‘What was done at your ast dental si? Preveus Dents Name. Addiess Stale a Telephone How often do you have dental examinations? How on do you brush your teeth? How fen co you oss? Have you ever used o are curenty using topical fuorde? Yes No What ther dental ats do ou use? (hela, ee) Doyou have any dental problems now? Yes No yes please desorbe ‘Ae ay of your teeth sensitive to: Have you ever had: Hotorcold? Yes No COrhodonicreatnent? Yes No ‘Sweets? Yes No Orel Surgery? Yes No Bitngor Chewing? Yes No Periodontal teatment? Yes No Have you noticed any mouth odor rad tastes? Yes No Yourleeh ground orthe bie adsed? Yes No Do you Fequenty ge cold srs, bisters or Abit late ormout qua? Yes No ‘anyother orlesons? Yes No Aserosinurytottemouhorhead? Yes No so, please dese, indudng case Doyourgumsbleedorhut? Yes No Have your parents experenoed gum disease cottoth iss? Yes No Have you experienced Have you noted any loose eth or change Citing oc popping oie jaw? Yes No inyourbie? Yes No Pain? (on ear, siecfface) Yes No Does fod tendo becom caughtin between Difctyn opening ocosing he mouth? Yes No yourtee? Yes No Dificuty in chewing on efter site ofthe mout? Yes No yes, where? Headaches, neckachesorshauder aches? Yes No ‘Sore muscles neck. showers)? Yes No Do you: Cench cr ind your tet wile awake orasleep? Yes No ‘Are you satisfied with your teeths appearance? Yes No Bit your ips or cheeks requay? Yes No ‘Would yout to eep af your teen allofyeurfe?” Yes No Hold foreign objects wih your tee? (pencls, dpe ons, nis, gerais) Yes No Do you fe ners about having del teatmen’? Yes No Mouth breathe wile ake orale? Yes No H so, whats your bigest concem? Have tired jus, especialy inthe moming? Yes No ‘Snore orhave any oer sleeping dsoves? Yes No Have you ever had an useing dental experience? Yes No SSmotechew bacco orusecherobacco products? Yes No yes please describe Have you eve been odo tke a presedicaon prot denial teatnen!? Yes. No Isthere anything else about having dental treatment that you woud ike us to know? Yes No yes, please dese. (Please complete other side) © Pride Institute FORMOIS (11.07) 1.800.925.2600 www. prideinstitute.com