Arbor dental health history and registration

WELCOME TO ARBOR DENTAL

Today’s Date: _________________________
E-Mail Address: __________________________________________________ Patient Name Last _________________________ First ___________________________ Middle Initial _________ Mr Mrs Ms Dr I prefer to be called ___________ Male__ Female __ Birthdate ______________ Age __________ Social Security # ___________________ Home Address ___________________________________ City ___________________________ State _______ Zip __________________ Single __ Married __ Divorced __ Widowed __ Separated __ Home #_______________ Work # _______________ Cel #______________ Employer _________________________________________ Occupation ______________________________________________________ Last Dental Visit ________________________ Whom may we thank for referring you to our office?_________________________________ PERSON RESPONSIBLE FOR ACCOUNT
Name Last ___________________________________ First _________________________________ Middle Initial ____________ Home Address ___________________________________ City ___________________________ State _______ Zip ___________ Birth Date _____________ Home Phone _______________ Work Phone ____________________ Cel Phone: ________________ Social Security # ____________________ D L # ______________________ Relationship to Patient ___________________ Employer __________________________________________ Occupation ____________________________________________________ SPOUSE INFORMATION
Name _____________________________ Birth Date ______________________ Social Security #_________________________ Work Phone _____________________ Employer ___________________________________ Occupation ____________________ EMERGENCY INFORMATION-RELATIVE NOT LIVING WITH YOU

Name ____________________________ Address ______________________________________ Phone ___________________
DENTAL INSURANCE (PRIMARY CARRIER) SECONDARY (complete if you have dual insurance coverage)

Insurance Co. __________________________________ Insurance Co. ______________________________________________
Insured's Name _________________________________ Insured's Name ____________________________________________ Insured's Employer ______________________________ Insured's Employer __________________________________________ Insured's Social Security # ________________________ Insured's Social Security #____________________________________ Group # ______________ Local # __________________ Group # _______________ Local # ____________________________ MEDICAL HISTORY

We need to know about your Medical & Dental History, this information is confidential.
Do you have a personal physician? Yes __ No __ Physician’s Name _________________________Phone ___________________
Are you currently under the care of a physician? Yes __ No __ Please explain _________________________________________ Your current physical health is: Good __ Fair __ Poor __ Last Exam ________________________________________________ Have you ever taken Fosamax, or any other bisphosphonate? Yes __ No __ Have you ever taken Phen-fen? Yes __ No __ Are you taking any prescription/over-the-counter or herbal supplement drugs? Yes __ No __ Please list each one: ________________________________________________________________________________________ _________________________________________________________________________________________________________ For Women: Are you pregnant? Yes __ No __ Are you nursing? Yes __ No __ Are you using a prescribed method of birth control? Yes __ No __



MEDICAL HISTORY continued
Have you ever had any of the fol owing diseases or medical problems? Please mark yes or no for each: Please list any serious medical condition(s) that you have ever had: ____________________________________________________________ ___________________________________________________________________________________________________________________ Are you allergic to any of the fol owing? Please mark yes or no for each: Please list any other drugs / materials that you are allergic to: _________________________________________________________________ DENTAL HISTORY
What brought you to the dentist today? __________________________________________________________________________________ Do you require antibiotics before dental treatment? Yes __ No __ Are you currently in pain? Yes __ No __ Do your gums ever bleed? Yes __ No __ Have you ever had a serious / difficult problem associated with any previous dental work? Yes __ No __ Do you now or have you ever experienced pain / discomfort in your jaw joint (TMJ / TMD)? Yes __ No __ Your current dental health is: Good __ Fair __ Poor __ Do you like your smile? Yes __ No __ Explain: _________________________________ Would you like whiter teeth? Yes __ No __ Fresher breath? Yes __ No __ Type of bristles? Soft __ Medium __ Hard __ How many times a week do you floss? _______________ a day do you brush? _________________ Do you smoke or use tobacco in any other form? Yes __ No __ Previous Dentist ___________________________________________________ SIGNATURE
Payment is due in ful at the time of treatment unless prior arrangements have been approved. I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information wil be held in the strictest confidence and it is my responsibility to inform this office of any change in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent. If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. Signature ______________________________________________________________Date__________________________________________ OFFICE USE ONLY
I verbal y reviewed the medical/dental information above with the patient named herein. Initials: __________________ Date: ____________ Doctor’s Comments: ____________________________________________________________________________________________________

Source: http://www.arbor-dental.com/med%20history.pdf