Patient Registration

Name

First

Middle

Last

Paitent is

Policy Holder
Responsible Party

Preferred Name

Responsible Party

If someone other than the patient

Name

First

Middle

Last

Address

Address 2

City, State, Zip

Home Phone

Work Phone

Ext

Cell Phone

Birth Date

Soc Sec

Drivers License

Policy Holder

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

Home Phone

Work Phone

Ext

Sex

Male
Female

Birth Date

Age

Soc Sec

Drivers License

Email

I would like to receive correspondences via email

Employment Status

Full Time
Part Time
Retired

Student Status

Full Time
Part Time

Employer ID

Carrier ID

Preferred Pharmacy

Preferred Dentist

Preferred Hyg

Employer

Primary Insurance Information

Name of Insured

Relationship to Insured

Self
Spouse
Child
Other

Insured Soc. Sec

Insured Birth Date

Employer

Employer Address

Employer Address 2

Employer City, State, Zip

Ins. Company

Address

Address 2

City, State, Zip

Rem. Benefits

Rem. Deduct

Secondary Insurance Information

Secondary Insurance: Name of Insured

Relationship to Insured

Self
Spouse
Child
Other

Insured Soc. Sec

Insured Birth Date

Employer

Employer Address

Employer Address 2

Employer City, State, Zip

Ins. Company

Address

Address 2

City, State, Zip

Rem. Benefits

Rem. Deduct

Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Are you under a 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 neck 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 other medications cotaining bisphosphonates?

Yes
No

If yes

Are you on a special diet?

Yes
No

If yes

Do you use tobacco?

Yes
No

If yes

Do you use controlled substances?

Yes
No

If yes

Women: Are you...

Pregnant/ Trying to get pregnant?
Nursing?
Taking oral contraceptives?

If yes

Do you have, or have you had, any of the following?

AIDS/ HIV Positive

Yes
No

Alzheimer's Disease

Yes
No

Anaphylaxis

Yes
No

Anemia

Yes
No

Angina

Yes
No

Arthritis/ Gout

Yes
No

Artifical Heat Vaule

Yes
No

Artifical Joint

Yes
No

Asthma

Yes
No

Blood Disease

Yes
No

Blood Transfusion

Yes
No

Breathing Problems

Yes
No

Bruise Easily

Yes
No

Cancer

Yes
No

Chemotherapy

Yes
No

Chest Pains

Yes
No

Cold Sores/ Fever Blisters

Yes
No

Congenital Heart Disorder

Yes
No

Convulsions

Yes
No

Cortisone Medicine

Yes
No

Diabetes

Yes
No

Drug Addiction

Yes
No

Easily Winded

Yes
No

Emphysema

Yes
No

Epilepsy or Seizures

Yes
No

Excessive Bleeding

Yes
No

Excessive Thirst

Yes
No

Fainting Spells/ Dizziness

Yes
No

Frequent Cough

Yes
No

Frequent Diarrhea

Yes
No

Frequent Headaches

Yes
No

Genital Herpes

Yes
No

Glaucoma

Yes
No

Hay Fever

Yes
No

Heart Attack/ Failure

Yes
No

Heart Murmur

Yes
No

Heart Attack/ Failure

Yes
No

Heart Pacemaker

Yes
No

Heart Trouble/ Disease

Yes
No

Hemophilia

Yes
No

Hepatitis A

Yes
No

Hepatitis B or C

Yes
No

Herpes

Yes
No

High Blood Pressure

Yes
No

High Cholesterol

Yes
No

Hives or Rash

Yes
No

Hypoglycemia

Yes
No

Irregular Heartbeat

Yes
No

Kidney Problems

Yes
No

Leukemia

Yes
No

Liver Disease

Yes
No

Low Blood Pressure

Yes
No

Lung Disease

Yes
No

Mitral Valve Prolapse

Yes
No

Osteoporosis

Yes
No

Pain in Jaw Joints

Yes
No

Parathyroid Disease

Yes
No

Psychiatric Care

Yes
No

Radiation Treatments

Yes
No

Recent Weight Loss

Yes
No

Renal Dialysis

Yes
No

Rheumatic Fever

Yes
No

Rheumatism

Yes
No

Scarlet Fever

Yes
No

Shingles

Yes
No

Sickle Cell Disease

Yes
No

Sinus Trouble

Yes
No

Spina Bifida

Yes
No

Stomach/ Intestinal Disease

Yes
No

Stroke

Yes
No

Swelling of Limbs

Yes
No

Thyroid Disease

Yes
No

Tonsillitis

Yes
No

Tuberculosis

Yes
No

Tumors or Growths

Yes
No

Ulcers

Yes
No

Venereal Disease

Yes
No

Yellow Jaundice

Yes
No

Have you ever had a serious illness not listed above?

Yes
No

If yes

Dental History

Dental complaint at this time

Last Dental Treatment on

Last Cleaning on

Grind/ Clench your teeth?

Yes
No

Have Jaw/ Joint Pain?

Yes
No

Have Sore/ Sensitive Teeth?

Yes
No

Have Bleeding Gums?

Yes
No

Have Cold/ Canker Sores?

Yes
No

Have Unpleasant Taste?

Yes
No

Are you happy with the way your teeth look?

Yes
No

Are you satisfied with the whiteness of your teeth?

Yes
No

Would you be interested in strightening your teeth without braces?

Yes
No

Are there any missing teeth that you would like to have replaced?

Yes
No

Do you have a fear of dentistry that keeps you from completing necessary dental procedures?

Yes
No

Is there anything about your smile that you would like to change:

Referral Source:

How did you hear about our office?

Friend/ Family member
Internet Search
Insurance referral list
Other referral source

Name of referral source

Emergency Contact Inforation

Emergency Contact Person

Phone

Relationship

Financial Responsibility:

The information given to the office of Stanley R. Waddell D.D.S. is true and I will notify the office of any changes, I hereby authorize any insurance benefits to go directly to Stanley R. Waddell DDS. I understand that I am responsible for any balance not paid for by insurance. All account balances are your responsibility. Any additional collection costs incurred to collect your account balance are your responsibilities.

Print Name

Responsible Party

Patient Information

Primary Insurance Information

Secondary Insurance Information

Medical History

Do you have, or have you had, any of the following?

Dental History

Referral Source:

Emergency Contact Inforation

Financial Responsibility: