• Anderson Dental, PC
  • PATIENT REGISTRATION
  • First Name:
  • Last Name:
  • Middle Initial:
  • Patient Is:
  • Policy Holder Responsible Party
  • Preferred Name:
    • Responsible Party (if someone other than the patient)
    • First Name:
    • Last Name:
    • Middle Initial:
    • Address:
    • Address 2:
    • City, State, Zip
    • Pager:
    • Home Phone:
    • Work Phone:
    • Ext:
    • Cellular:
    • Birth Date:
    • Soc Sec:
    • Drivers Lic:
    • Responsible Party is also a Policy Holder for Patient
      Primary Insurance Policy Holder
      Secondary Insurance Policy Holder
    • Patient Information
      • Address:
      • Address 2:
      • City:
      • State / Zip:
      • Pager:
      • Home Phone:
      • Work Phone:
      • Ext:
      • Cellular:
      • Sex:
      • Male Female
      • Marital Status:
      • Married Single Divorced Separated Widowed
      • Birth Date:
      • Age:
      • Soc. Sec:
      • Drivers Lic:
      • E-mail:
      • I would like to receive correspondences via e-mail.
      • Section 2
      • Section 3
        • Employment Status:
        • Full Time Part Time Retired
        • Student Status:
        • Full Time Part Time
        • Medicaid ID:
        • Pref. Dentist:
        • Employer ID:
        • Pref. Pharmacy:
        • Carrier ID:
        • Pref. Hyg.:
        • License #:
        • Mobile Phone #:
        • Spouse #:
        • In Case of Emergency:
        • Emergency Phone #:
      • Primary Insurance Information
      • Name of Insured:
      • Relationship to Insured:
      • Self Spouse Child Other
      • Insured Soc. Sec:
      • Insured Birth Date:
        • Employer:
        • Address:
        • Address2:
        • City, State, Zip:
        • Ins. Company:
        • Address:
        • Address 2:
        • City, State, Zip:
        • Rem. Benefits:
        • .00
        • Rem. Deduct:
        • .00
      • Secondary Insurance Information
      • Name of Insured:
      • Relationship to Insured:
      • Self Spouse Child Othe
      • Insured Soc. Sec:
      • Insured Birth Date:
        • Employer:
        • Address:
        • Address2:
        • City, State, Zip:
        • Rem. Benefits:
        • .00
        • Rem. Deduct:
        • .00
        • Ins. Company:
        • Address:
        • Address 2:
        • City, State, Zip:
    • Anderson Dental, PC
    • Medical History
    • Patient Name
    • Birth Date
    • Date Created
    • Are You Under physician's care now ?
    • Yes No
    • If Yes
    • Have you ever been hospitalized or had a major operation ?
    • Yes No
    • IF Yes
    • Have you ever had a serious head or neack injury?
    • Yes No
    • If Yes
    • Are you taking any medications, pills, or drugs?
    • Yes No
    • If Yes
    • Do you take, or have you taken, phen-fen or redux?
    • Yes No
    • If Yes
    • Have you ever taken Fosamax, Boniva, Actonel or any
    • Yes No
    • If Yes
        • other medications containning bisphosphonates?
        • Are you on a special diet?
        • Yes No
        • Do you use tobacco?
        • Yes No
        • Do you use controlled substances?
        • Yes No
        • If Yes
    • Women: Are You...
    • Pregnant/Trying to get pregnant ?
    • Nursing
    • Taking oral contraceptives?
    • Are you allergic to any of the following?
    • Aspirin
    • Penicillin
    • Codeine
    • Acrylic
    • Metal
    • Latex
    • Sulfa Drugs
    • Local Anesthetics
    • Other?
    • Yes No
      AIDS/HIV Positive
      Alzheimer's Disease
      Anaphylaxis
      Anemia
      Angina
      Arthritis/Gout
      Artificial Heart Value
      Artificial Joint
      Asthma
      Blood Disease
      Blood Transfusion
      Breathing Problems
      Bruise Easily
      Cancer
      Chemotherapy
      Chest Pains
      Cold Sores/Fever Blisters
      Congenital Heart Disorder
      Convulsions
      Cortisone Medicine
      Diabetes
      Drug Addiction
      Easily Winded
      Emphysema
      Epilepsy or Seizures
      Excessive Bleeding
      Excessive Thirst
      Fainting Spells/Dizziness
      Frequent Cough
      Frequent Diarrhea
      Frequent Headaches
      Genital Herpes
      Glaucoma
      Hay Fever
      Heart Attack/Failure
      Heart Murmur
      Heart Pacemaker
      Heart Trouble/Disease
    • Yes No
      Hemophilia
      Hepatitis A
      Hepatitis B or C
      Herpes
      High Blood Pressure
      High Cholesterol
      Hives or Rash
      Hypoglycemia
      Irregular Heartbeat
      Kidney Problem
      Leukemia
      Liver Disease
      Low Blood Pressure
      Lung Disease
      Mitral Valve Problems
      Osteoporosis
      Pain in Jaw Joints
      Parathyroid Disease
      Psychiatric Care
      Radiation Treatments
      Recent Weight Loss
      Recent Dialysis
      Rheumatic Fever
      Rheumatism
      Scarlet Fever
      Shingles
      Sickle Cell Disease
      Sinus Trouble
      Spina Bifida
      Stomach/Intestinal Disease
      Strock
      Swelling of Limbs
      Thyroid Disease
      Tonsillitis
      Tuberculosis
      Tumors or Growths
      Ulcers
      Venereal Disease
      Yellow Jaundice
    • Have You ever had any serious illness not listed above?
    • Yes No
    • If Yes?
    • Comments
    • To the best of my knowledge, the question on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.
    • Signature
    • Date:
  • Anderson Dental, PC
  • 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 Practice
  • (Please Print Name). Child
  • (Please Print Name). Parent
  • Signature
  • Date
  • For Office Use Only
  • We attempted to obtain written acknowledgement of receipt of our Notice
  • of privacy practice, but acknowledgement could not be obtained because
  • •Individual refused to sign
  • •Communications barriers prohibited obtaining the acknowledgement
  • •An emergency situation prevented us from obtaining acknowledgement Other (Please Specify)
  • _________________________________________________________________________________________________

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