PATIENT REGISTRATION FORM

Paul Y. Lin, D.D.S.

Cosmetic, Restorative, & General Dentistry

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IF YOU ARE COVERED THROUGH SOMEONE OTHER THAN YOURSELF, PLEASE COMPLETE THIS SECTION FOR THE PRIMARY INSURED (PRIMARY SUBSCRIBER).

IF YOU ARE COVERED THROUGH SOMEONE OTHER THAN YOURSELF, PLEASE COMPLETE THIS SECTION FOR THE PRIMARY INSURED (PRIMARY SUBSCRIBER).

Paul Y. Lin, D.D.S.

Cosmetic, Restorative, & General Dentistry

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have or medications that you may be taking could have an important interrelationship with the treatment you will receive in our office. Thank you for answering the following questions.

If Yes, please provide the physician's name and treatment (if other than regular check-up)

If Yes, please provide details.

If Yes, please list them

If Yes, please provide when and duration.

If Yes, please provide when and duration

If Yes, please provide details.

If Yes, please provide how long and how much

If Yes, please provide details.

You are pregnant or trying to get pregnant.You are nursing.You are taking contraceptives.

Please List All Others You Are Allergic To

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Please contact the office for any questions or issues.

82 Townsend Street,

San Francisco, CA 94107

Tel.415. 543.6882

info@PaulYLinDDS.com

PATIENT REGISTRATION FORM

DENTAL INSURANCE INFORMATION

SECONDARY INSURANCE COVERAGE:

Whom May We Thank for Referring You to Our Office

PATIENT MEDICAL HISTORY

IF YOU HAVE EVER HAD ANY SERIOUS ILLNESS OR CONDITION NOT LISTED ABOVE. PLEASE EXPLAIN

COMMENTS OR ANYTHING ELSE WE SHOULD BE AWARE OF?