REGISTRATION & MEDICAL HISTORY FORM

PLEASE READ THIS BEFORE BEGINNING THIS FORM:

It is best to be organized for this form - Collect the Following:

1. Dental Insurance Information and a Copy of your Insurance Card (if you have one).

2. Prescriptions - If you have a list already prepared you can attach it to this form. If you don't have a formal list you will be asked for

a) Name of each Medication

b) Dose & Frequency

c) Purpose (Example: High Blood Pressure)

d) Prescribing Physician (or self)

3. Supplements, Vitamins, & Over the Counter Medications - If you have a list already prepared you can attach it to this form. If you don't have a formal list you will be asked for

a) Name of each Item

b) Dose & Frequency

c) Purpose

d) Prescribing Physician (or self)

3. Physicians - Contact Information including the name, specialty, phone, city, and other information if you have it.

4. Photo ID (It is not required but helpful!)
Date Completing:

Month Day Year
Date
Patient's Name: *

Prefix First Name Last Name Suffix
Patient's Name:

First Name Last Name
Nickname:
Nickname
Sex: *

Male Female
Date of Birth: *

Month Day Year
Date of Birth
DOB
Today for age calculation:

Month Day Year
Date
Age Days: For Calculation
Age:
Legal Consent: Patients under 18 cannot give consent. Other patients due to mental or other circumstances may not be capable of giving consent. For scheduling surgeries it is important to identify who we need to communicate with to coordinate care. Please call our office if you have any questions.
Is the Patient Able to Provide Legal Consent? *

YES NO
Height: *
Example: 5' 8"
Weight: (lb.) *
Example: 130
Marital Status: *

Single Married Separated Divorced Widowed
Address: *

Street Address

Street Address Line 2

City State

Zip Code
Test Address
Primary Contact Method:

Mobile - Call E-mail Text
Primary Contact Number: *
This is the 1st Number we will call.
Do you have an Email Address?

YES NO
Primary Contact Email:
example@example.com
Contact for Pre-Appointment Arrangements? *

Patient Spouse Family Member Caregiver Other

Job/School/Retired: *

Student Employed Retired Unemployed
School - Occupation - Employer
If Retired, Please provide your past occupation & employer
Accommodations: *

No Accommodations Needed Special Needs - Autism etc. Memory Issues/Dementia Mobility Issues Developmental Issues Wheel Chair Nursing Home/Assisted Living Language Other
Accommodations? N

NO
Accommodations? Y

YES
Special Needs: Please check all that apply

Autism Non-Verbal Verbal Understands & Able to Communicate Lives in Group Home Cooperative Unable to Cooperate Downs Syndrome Requires Sedation for Dental Appointments
Wheel Chair Add'l Info.
Is the patient able to transfer? Please note any other accomodations.
Accommodations Additional Information:
Please detail ANY accommodations here.

Number for Dr. Alman to Call to Check on the Patient the Evening of Surgery or Procedure? *

Main Contact (Already Provided) 2nd Contact (Already Provided) Other Number
Night of Procedure Contact Information:

	Medical Surrogate:
Name:
Relationship:
Telephone:
Email:
Address:


Subscriber's Name:
DOB:
Sex:
Address (If Different)


Member ID:
Group #:
Insurance Name:
Claims Address:


Subscriber's Name:
DOB:
Sex:
Address (If Different)


Member ID:
Group #:
Insurance Name:
Claims Address:

Do you have DENTAL Insurance? *

YES NO
DENTAL INSURANCE:

Oral surgery procedures may be covered by dental insurance. Dr. Alman is NOT a perferred provider for any insurance plans. HMOs & Discount Plans do not have any out of network benefits.

If you have coverage has out-of-network benefits we will be pleased to assist by filing a claim on your behalf. We are filing for you to be reimbursed according to the out-of-network benefits available.
Member/Subscriber?

Self Spouse Parent

Non-Participation:
Please attach a copy of the DENTAL insurance card:

BOTH SIDE PLEASE
Cancel of


Subscriber's Name:
DOB:
Sex:
Address (If Different)


Member ID:
Group #:
Insurance Name:
Claims Address:

Are you in GOOD HEALTH? *

YES NO
Do you see a medical doctor for ANY reason other than routine care? *

YES NO
Your Physician's Contact Information may be needed to contact them for medical clearance or medical manaagment. If you see multiple specialists please gather their information as well for later at the end of this form add each Name, Specialty, Telephone Number, Email, and Fax Number. We don't need the address but, the City, and State is appreciated.
Has there been any changes to your general health in the last 2 years? *

YES NO
Past 2 years changes to general health.
Please describe any changes to your general health in the last 2 years.
Have you had an Illness, Operation, or been Hospitalized in the past 5 years? *

YES NO
Illness, Operation, or Hospitalization Additional Information:
Please describe the Illness, Operation, or Hospitalization including dates. You can attach any medical records later on this form.

Do you have any Prosthetic Joints (Joint Replacements such as hip or knee)? *

YES NO
Prosthetic Joint(s) Add'l Info.
Please provide details on which Joints & How Long Ago (Year is Helpful).
Does your Physician advise taking an Antibiotic prior to a Dental Procedure? *

YES NO
Are you on an Antibiotic now? *

YES NO
Antibiotic - Currently Taking

	Coumadin (Warfrin) - INR Last Test Results:
Last Test Date:
INR Reading:

	Smoking Details:
List Products:
How Long? Years?
How Much Per Day?
If Quit When?

General Practitioner (GP):


Physician's Name:
Specialty:
Telephone:
Email:
Fax:
City, State:
Date of Last Visit:

Other:


Physician's Name:
Specialty:
Telephone:
Email:
Fax:
City, State:

Payment for the Services will be paid by: (AMEX is not available) *

Check Visa Master Card Discover Cash
Financial Agreement: *
Health History: *
Overall Form Acknowledgment: *
Privacy: *
Please attach a copy of the MEDICAL insurance card:

BOTH SIDE PLEASE
Cancel of
Please attach a recent photo or an ID of the patient:

This is for our records.
Cancel of
PHOTOS: As an option - You may also take photos of your ID, referral, and other information.
REFERRAL: This may have already been sent by your referring dentist:

This is the work order request.
Cancel of
X-RAYS: Attach any X-rays (Often they are sent electronically by the referring dentist):

Occasionally the referring dentist wants our office to take the x-ray.
Cancel of
Signature:

Please sign here. Clear
Should be Empty:

	Reading/Level	Last Test Date
A1C
Blood Glucose

	Main Contact	2nd Contact
Name:
Relationship:
Telephone:
Email:

	For Appointments:	Financial Contact:
Organization:
Name:
Telephone:
Email: