Lisa C. Lavinder, D.D.S. / Stephen R. Quinn, D.D.S.
Adam C. Williams, D.D.S. / B. Scott Ward, D.D.S.
Priya A. Acharya, D.M.D. / Adam M. Park, D.D.S.
Patient Registration
Date______
Patient Information (Confidential)
Name: ______□Male □ Female Spouse’s Name: ______
Birth Date: ______Social Security #: ______
Address: ______City/State/Zip: ______
Phone Numbers: Home: ______Work:______Cell: ______
Email Address: ______
Check Appropriate Box: □ Minor □ Single □ Married □ Divorced □ Widowed □ Separated □ College Student
Patient’s or Parent’s Employer: ______
Emergency Contact: ______Phone Number: ______Relationship: ______
Responsible Party (person responsible for the account balance after insurance)
Name of person responsible for this account: ______Relationship to Patient: ______
Address: ______Home Phone: ______
Birth Date: ______Social Security #: ______
Signature of Responsible Party: ______
Insurance Information (person who carries the insurance policy)
Name of Insured: ______Relationship to Patient: ______
Birth Date of Insured: ______Social Security # of Insured: ______
Name of Employer: ______Work Phone: ______
Insurance Company: ______Policy/I.D. #: ______
PATIENT MEDICAL HISTORY: Please check and list any of the following that apply
□ Cigarettes (amount per day) □ Chew/Pipe (amt) ___ (years) ___ □ Currently Pregnant
□ Hepatitis A, B, C, D □ Cancer ______□ Swollen Ankles
□ AIDS or HIV Infection □ Chemo Yes/No Radiation Yes/No □ High / Low Blood Pressure
□Allergies ______□ Diabetes – Insulin / Meds □ Stroke
□Latex Allergy □ Epilepsy – Convulsions □ Thyroid Disease
□ Anemia □ Heart Disease □ Migraine Headaches
□Hypoglycemia □ Heart Surgery ______□ Neurological Disorders
□Arthritis □ Heart Attack / Chest Pains □ Psychiatric Treatment
□ Artificial/Replaced Joints ______□ Heart Murmur □ Emphysema
□ Organ Transplant ______□ Premed Yes / No □ Respiratory Problems
□ Asthma/Inhaler Yes / No □ Cardiac Pacemaker □ Kidney Disease
□Blood Disease □ Mitral Valve Prolapse □ Liver Disease
□ Breast Implants – Premed Yes / No □ Rheumatic Fever □ Tuberculosis
Please turn over►
MEDICAL HISTORY CONTINUED…
Any disease, condition or problem being treated by a physician not listed above: ______
Are you taking medications?: ______If so, what?: ______
Name of Physicians: ______
PATIENT DENTAL HISTORY:
□ Tooth sensitivity (hot/cold/sweets/pressure) □ Allergies to jewelry Yes / No
□ Bleeding gums □ Unusual sounds in ear while eating
□ Bad Breath – Unpleasant Taste □ Fingernail or cheek biting
□ Food impaction □ Mouth breathing
□ Clenching or Grinding □ Swelling or lumps in mouth
□ Pain around ear – Right or Left □ Orthodontic Treatment – Year _____
□ Frequency of brushing (times per day) ____ □ Complications from extractions
□ Frequency of flossing (times per week)____ □ Frequent blisters on lips or in mouth
□ Mouth rinse (brand) ______□ Texture of toothbrush – soft/medium/hard
□ Fluoride rinse / gel (brand) ______□ WaterPik or other hygiene aids ______
□ Toothpaste (brand) ______□ Fluoridated water / well water
Name of Previous Dentist: ______Date of last dental exam: ______
May we request your dental records?: ______Purpose of appointment today: ______
Referred by: ______
Have you ever been treated for periodontal disease? Yes / No
If yes, when: ______where: ______How was the infection treated?:______
Do you wear dentures or partials? Yes / No If yes, date of placement: ______
Authorization
I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf of my dependents. I understand that any unpaid balances are subject to a 50% penalty if forwarded to a collection agency. In order to best service my account, I understand that I may be contacted at any telephone number associated with my account, including wireless numbers. Methods of contact may include using pre-recorded/artificial voice messages and/or the use of an automatic dialing device, as applicable.
Signature of Patient (or parent if a minor): ______Date: ______
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
*you may refuse to sign this acknowledgement*
I, ______, have received a copy of this office’s Notice of Privacy Practices.
Date ______