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Microsoft word - registration form-revised.doc

MID-COUNTY ENDODONTIC GROUP, P.A.
60 W. RIDGEWOOD AVE. RIDGEWOOD NJ 07450 201.652.3311
250 KINDERKAMACK RD. WESTWOOD NJ
07675 201.666.4546
PATIENT REGISTRATION
Date:_________________ Patient’s Name:_________________________________________________________________ Title: ___________ Parent’s name (if patient is a minor):_______________________________________ Date of Birth: __________________ SS# ____________________________ Marital status: ____________ Sex: ______ Home Address:_________________________________________City__________________State_______Zip_________ Home Phone: __________________________________ Cellular Phone: ____________________________________ Employer : ________________________________________________ Work Phone: ____________________________ Person responsible for account:_______________________________ General Dentist:_______________________________________ Referred by:_______________________________ Have you been a patient with us before? _________ MEDICAL HISTORY

Are you currently under the care of a physician? □Yes □No For what condition? ____________________________ If yes, name and phone # of your physician:________________________________________________________________ Do you take an aspirin a day? □Yes □No Do you take coumadin? □Yes □No Are you currently taking or have you previously taken Bisphosphonate medications such as: Fosamax, Actonel or Zometa within the past 12 months? □Yes □No Are you currently taking immune suppressive medications such as Corticosteroids?
Have you had or do you currently have?
Please circle
٭Congenital heart defects
٭Radiation therapy to Head/Neck w/in 12 months Seizures *You must be pre-medicated with antibiotic prior to your dental appointment. For consultations, no need for pre-medication.

Please list all medications you are currently taking:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Have you had any allergic reactions to the following? Please circle
Do you have any history of substance abuse? □Yes Is there any other medical/dental condition the treating doctor should know? If yes, please explain: ___________________________________________________________________________________ I certify that the information on these pages are correct and accurate. I also certify that I am the patient (or authorized agent of the patient) authorized to furnish all information requested. Patient / (or Guardian) Signature: _______________________________________________________
Dental Insurance Information
Insurance company name and address: __________________________________________________________________ Subscriber’s name : _________________________________ SS# ________________________ DOB:________________ Subscriber address: __________________________________________________________________________________ Subscriber’s employer name and address: Group or Policy # : ___________________________________ Secondary insurance company name and address: _________________________________________________________ Subscriber’s name : _________________________________ SS# ________________________ DOB:________________ Subscriber’s employer name and address: Group or Policy # : ___________________________________ RETURN VISIT UPDATE
(For patients who have not been seen at our office for over a year) Have there been any changes in your medical history since your last visit? □Yes Comments ________________________________________________________________________________________
_________________________________________________________________________________________________
Signature: _____________________________________________

Source: http://www.midcountyendo.com/pdf/registrationform.pdf

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