REGISTRATION & MEDICAL HISTORY FORM

10/12/22: OUR OFFICE IS STILL REQUIRING FACEMASKS

The CDC’s guidelines for enhanced respiratory protection remains in place for health care facilities, including private dental offices. updated 09/23/22

PLEASE READ THIS BEFORE BEGINNING THIS FORM:

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

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)

e) Include any Supplements, Vitamins, & Over the Counter Medications

3. Physicians Contact Information - name, specialty, phone, and city
Date Completing:

MonthDay Year
Date
Patient's Name:*

Prefix First Name Last Name Suffix
Patient's Name:

First Name Last Name
Nickname:
Nickname:
Nickname
Sex:*

MaleFemale
Female:
Date of Birth:*

MonthDay Year
Date of Birth
DOB
Today for age calculation:

MonthDay 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?*

YESNO
Patient is Under 18
Weight: (lb.) *
Example: 130 (Only Whole Numbers)
Height: Feet*
Example: 5 (Whole Number)
Height: Inches
Only Whole Numbers 1 - 11
Total Inches
BMI:
Marital Status:*

SingleMarriedSeparatedDivorcedWidowed
Address:*

Address
Street Address Line 2
City State
Zip Code
Primary Contact Method:

Mobile - CallE-mailTextLandline - Home Number
Primary Contact Number:*
This is the 1st Number we will call.
Do you have an Email Address?

YESNO
Primary Contact Email:
example@example.com
Contact for Pre-Appointment Arrangements?*

PatientSpouseFamily MemberCaregiverOther
Person to Contact if Not Patient:

Main Contact 2nd Contact
Name:
Relationship:
Telephone:
Email:
Job/School/Retired:*

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

No Accommodations NeededSpecial Needs - Autism etc.Memory Issues / DementiaDevelopmental ProblemsWheel ChairHearing ProblemsNursing Home / Assisted LivingLanguageUnable to Swallow PillsOther
Unable To Swallow Pills:
Please Provide Details
Hearing: How can we best help with your appointment?
Note any details to help have a great experience.
Special Needs: Please check all that apply

AutismNon-VerbalVerbalUnderstands & Able to CommunicateLives in a Group HomeCooperativeUnable to CooperateDowns SyndromeDevelopmental IssuesRequires Sedation for Dental AppointmentsOther
Wheel Chair:
Is the patient able to transfer to a dental chair?

Able to transfer to a dental chairUnable to transfer without assistance
Wheel Chair Additional Information
Please note any other accomodations.
Accommodations Additional Information:
Please detail ANY accommodations here.
Patient Case Coordinator:

For Appointments: Financial Contact:
Organization:
Name:
Telephone:
Email:
Medical Surrogate - Guardian:

Medical Surrogate:
Name:
Relationship:
Telephone:
Email:
Address:
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
Name & Relationship to Patient
Name & Relationship to the Patient
Number to Call
Number to Call Evening of Surgery
OLD: Night of Procedure Contact Information:

	Reading/Level	Last Test Date
A1C
Blood Glucose

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


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


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


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

	General Practitioner (GP)
Physician's Name:
Specialty:
Telephone:
Email:
Fax:
City, State:
Date of Last Visit:

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

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

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