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PATIENT REGISTRATION FORM

1. ABOUT YOU

Name:*

I prefer to be called:

Sex*

Male Female

If child, parents name:

Birth date:

Age:

SS #:

Home address:*

City/State/Zip:*

Email address:*

Marital status:*

Home phone #:

Work Phone #:

Cell #:

Employer:

Employer’s address:

City/State/Zip:

Occupation:

How long there?

Where & when are best times to reach you?

Who may we Thank for referring you?

Purpose of this appointment?*

2. SPOUSE INFORMATION

Spouse Name:

Birth date:

Employer:

Occupation:

Address:

City/State/Zip:

Work phone & Ext #:

SS #:

Cell #:

Person responsible for Account:*

Self (patient) Spouse Parent Other

Name of responsible*

Work#:

Ext:

Home#:

Billing Address:

City/State/Zip:

Relationship:

SS #:

Employer:

Birthdate:

3. DENTAL INSURANCE

Primary Dental Insurance

Insured's / Insurance Information:*

Self (patient) Spouse Parent Other

Insurance Co. Name:*

Insurance Co. Phone #:*

Insurance Co. Group #:

Insurance co ID#:*

Insured’s Name:

Relation:

Insured’s Birthdate:

Insured’s SS #:

Insured’s Employer:

Address:

City/State/Zip :

Secondary Dental Insurance

Insured's / Secondary Insurance Information

Secondary Insurance Co. Name:

Insurance Co. Phone #:

Insurance Co group#:

insurance co ID#:

Insured’s Name:

Relation:

Insured’s Birthdate:

Insured’s SS #:

Insured’s Employer:

Address:

City/State/Zip:

I authorize the release of information necessary for the processing of insurance claims and assign benefits to Dr. Charles C. Clausen, D.D.S., P.C.

Signature

In case of emergency, whom should be notified?

Relationship to patient

Phone # of emergency contact:

4. FINANCIAL RESPONSIBILITY

I acknowledge that I am responsible for all charges for services provided, including any amount not paid by my insurance plan. If collection procedures become necessary I agree to pay all attorney and collection fees.

I acknowledge I have received a copy of this office’s Notice of Privacy Practices.

I also authorize the release of all dental information necessary for processing insurance claims to my insurers or any third party or their agents.

I understand that 48 business hours notice for cancellations is required or I may be subject to a $75 service fee.

PATIENT/INSURED SIGNATURE:

DATE

5. MEDICAL / DENTAL HISTORY

Physician’s Name:

Phone #:

Date of last visit:

Height:

Weight:

Blood Pressure:

Your current physical health is:

Good Fair Poor

Are you currently under the care of a physician?

Yes No

Please explain:

Are you taking any medications?

No Yes

Are you taking any herbal supplements?

No Yes

Please list all medications and herbal supplements:

When was your last dental appointment?

Purpose of last dental appointment

When was your last full mouth X-Ray taken?

Where?

For Women: Are you taking any birth control pills?

No Yes

Are you pregnant?

No Yes

Week#:

Are you nursing?

No Yes

Do you have or have you ever had:

Blood Transfusion:

No Yes

Severe/Frequent headaches:

No Yes

Please list cause of headaches:

Pain in or near your ears:

No Yes

Growth or sore spots in your mouth:

No Yes

Please list cause of ear pain

Mouth hurts when clenched:

No Yes

Gums bleed:

No Yes

Do you at the present time have any dental complaints:

No Yes

Do you habitually clench your teeth during the night or day:

No Yes

Any part of your mouth sore to pressures or irritants (cold, sweets, etc.)

No Yes

Do you use tobacco products:

No Yes

Are you allergic to:

Penicillin:

No Yes

Local anesthetic:

No Yes

Other medications or drugs:

Have you been hospitalized in the last 5 years

No Yes

If so, for what:

Do you have or have you ever had:

Do you take aspirin?

No Yes

Do you take blood thinners?

No Yes

Do you take bisphosphonates?

No Yes

HIV Positive

No Yes

Anemia

No Yes

Asthma

No Yes

Diabetes

No Yes

Epilepsy or Seizures

No Yes

Hepatitis

No Yes

Rheumatic Fever

No Yes

Artificial Joints

No Yes

Heart Murmur

No Yes

Mitral Valve Prolapse

No Yes

Abnormal Heart Condition

No Yes

Abnormal Bleeding From A Cut

No Yes

Abnormal Blood Pressure

No Yes

Respiratory Disease

No Yes

Pulmanory Shunts

No Yes

Rheumatism or Arthritis

No Yes

Tumors or Growths

No Yes

Any Blood Disease

No Yes

Any Liver Disease

No Yes

Any Kidney Disease

No Yes

Any Stomach or Intestinal Disease

No Yes

Any Venereal Disease

No Yes

Please list any conditions not listed above:

7. APPEARANCE SATISFACTION

Are you satisfied with the appearance of your teeth?

No Yes

If NO, what concerns do you have about the appearance of your teeth?

What changes, if any, would you like to make to your smile?