New Patient Registration

Person Responsible for Bill or Parent

(Complete only if different from patient)
Guarantor Name:

First NameMiddle NameLast Name
Guarantor's Address
Please type Street, City, State and Zip Code
Guarantor's Date of Birth

MonthDayYear
Social Security Number
Relationship to the Patient
Guarantor's Phone Number

Area CodePhone Number
Guarantor's Work Information
Employer Name
Employer Phone Number

Area CodePhone Number
Employer Address
Emergency Contact
Name

First NameLast Name
Relationship
Primary Phone

Area CodePhone Number
Secondary Phone

Area CodePhone Number

Health History

Please answer all questions.
Are you in good health?
Have you been under a physician' care during the past year?
If you answered 'Yes' to recently being under a doctor's care, please explain.
Physician's Name
Physician's Phone Number

Area CodePhone Number
Have you taken any kind of medicine or drugs the past year? If yes, list all medications in the next question.
LIST ALL CURRENT MEDICATIONS HERE - If None, please write "No Medications"
Are you allergic to penicillin or any other drugs or food?
If yes to drug or food allergies, please explain.
Have you had any other surgery or serious illness?
If yes, please explain:
Have you ever had any excessive bleeding requiring special treatment?
If yes, please explain:
Are you wearing contact lenses?
Are you allergic to latex?
Have you ever had a problem with general anesthesia?
Do you take bisphosphonates/calcium replacements? (Ex: Fosamax, Aredia, Didronel, Actonel, Boniva, Zometa)
Do you use alcohol?
If yes, how much alcohol per day?
Do you smoke?
If yes, how long have you smoked?
Are you or have you been in a drug or alcohol recovery program (Suboxone/Methadone)?
Do you have any other disease, condition or problem not listed that the doctor should know about?
If yes, please explain.

Person Responsible for Bill or Parent