PATIENT REGISTRATION

Maureen L. O’Flanagan, D.D.S.

Date:


First Name:    Last Name:

Patient Is:

Policy Holder
 Responsible Party

Patient Information


Address:   Address 2:

City:   State / Zip: /

Home Phone:   Cell Phone: Work Phone: Ext:

Sex:   Male Female                Marital Status:    Married  Single Divorced Separated Widowed

Birth Date:    Age:    Social Security Number:

E-Mail:     I would like to receive correspondences via e-mail.

Emergency Contact Name:    Emergency Contact Phone:

Employer Name:    Pharmacy Phone:


Responsible Party (if someone other than the patient)


First Name:   Last Name:

Address:   Address 2:

City, State, Zip:

Home Phone: Cell Phone: Work Phone: Ext:

Birth Date: Social Security Number:

Responsible Party is also a Policy Holder for Patient     Primary Insurance Policy Holder Secondary Insurance Policy Holder


Dental Insurance Information                Group Number ID #


Name of Insured:  Relationship to Patient:   Self Spouse Child Other

Employer:  Employer Address:

Employer City, State, Zip:  Employer Address 2:

Ins. Company:  Ins. Co. Address:

Ins. Co. City, State, Zip:  Phone Number:

Ins. Social Security Number Ins. Date of Birth:

 

Secondary Dental Insurance Information                                 Group Number


Name of Insured:    Relationship to Patient:    Self     Spouse     Child     Other

Employer:    Employer Address:

Employer City, State, Zip: Employer Address 2:

Ins. Company:    Ins. Co. Address:

Ins. Co. City, State, Zip:    Phone Number:

Ins. Social Security Number Ins. Date of Birth:

 


                                                                         MEDICAL HISTORY

Patient Name:

Although dental personnel primarily treat the area in and around your mouth, your mouth is part of your entire body. Health problems 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 for any illness or health problem? Yes No N/A

                                                             (for the last two years)

Date of last exam:
Physicians:        1: Phone: Specialty:

Physicians:        2: Phone: Specialty:

Physicians:        3: Phone: Specialty:

Have you ever been hospitalized or had a major operation? Yes No N/A

Have you ever had a serious head or neck injury? Yes No N/A

Are you taking any medications, pills, or drugs? Yes No N/A

Do you take, or have you taken, Phen-Fen or Redux? Yes No N/A         Do you use tobacco? Yes No N/A

Are you on a special diet? Yes No N/A                             Do you use controlled substances? Yes No N/A

Women:   Are you Pregnant/Trying to get pregnant? Nursing? Taking oral contraceptives?

Are you allergic to any of the following?

Aspirin Penicillin Codeine Acrylic Latex Local Anesthetics Erythromycin

Other

 

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

AIDS/HIV Positive
 Alzheimer’s Disease
 Anaphylaxis
 Anemia
 Angina
 Arthritis/Gout
 Artificial Heart Valve*
 Artificial Joint*
 Asthma
 Blood Disease
 Blood Transfusion
 Breathing Problem
 Bruise Easily
 Cancer
 Chemotherapy

Chest Pains
 Cold Sores/Fever Blisters
 Congenital Heart Dis.
 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 Pace Maker*
 Heart Trouble/Disease
 Hemophilia
 Hepatitis A
 Hepatitis B or C
 Herpes
 High Blood Pressure

Hives or Rash
 Hypoglycemia

Irregular Heartbeats
 Kidney Problems
 Leukemia
 Liver Disease
 Low Blood Pressure
 Lung Disease
 Mitral Valve Prolapse*
 Pain in Jaw Joints
 Parathyroid Disease
 Psychiatric Care
 Radiation Treatments
 Recent Weight Loss
 Renal Dialysis
 Rheumatic Fever*
 Rheumatism

Scarlet Fever
 Shingles

Sickle Cell Disease

Sinus Trouble
 Spina Bifida

Stomach/Intestinal Dis.

Stroke

Swelling of Limbs

Thyroid Disease

Tonsillitis

Tuberculosis

Tumors or Growths

Ulcers
 Venereal Disease

Yellow Jaundice

 

Have you had any serious illness not listed above? Yes No N/A

Comments:

*Condition may require medication                         N/A = Not Answered By Patient

To the best of my knowledge, the questions 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 OF PATIENT, PARENT, or GUARDIAN    Date: