Patient Registration
PATIENT INFORMATION
This appointment is for
*
Yourself
Your Child
Your Spouse
Other
Please specify
*
Name
*
First Name
Middle Name
Last Name
Social Security Number
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Male
Female
Other
Please specify gender
Home Address
*
Street, City, State. Zip
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Mailing Address
*
Not the same as home address
Same as home address
Mailing Address
Street, City, State. Zip
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Occupation
Employer
Full Time Student
*
Yes
No
School Name
*
Previous Dentist
Current Physician
Whom may we thank for referring you
Internet
Insurance
Other
Please specify
CONTACT INFORMATION
Home Phone
-
Area Code
Phone Number
Cell Phone
*
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
Email
*
example@example.com
EMERGENCY CONTACT
Emergency Contact Name
*
First Name
Last Name
Relationship
Home Phone
-
Area Code
Phone Number
Cell Phone
*
-
Area Code
Phone Number
RESPONSIBLE PARTY
Who is responsible for this patient?
*
Myself
Someone Else
Name
*
First Name
Middle Name
Last Name
Social Security Number
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Male
Female
Other
Please specify Gender
Occupation
Employer
Home Phone
-
Area Code
Phone Number
Cell Phone
*
-
Area Code
Phone Number
INSURANCE INFORMATION
Dental Coverage
*
Yes
No
Insurance Policy Number
Group Policy Number
Insurance Co. Name
Insurance Co. Phone
-
Area Code
Phone Number
Insured’s Full Name
First Name
Middle Name
Last Name
Relationship
Social Security Number
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
MEDICAL INFORMATION
Physician’s Name
Physician’s Phone
Last Exam
Current physical health?
*
Good
Fair
Poor
If "Yes" Please Describe
*
Hospitalized within the past 5 years?
*
Yes
No
If "Yes" Please Describe
*
Taking any prescription/over-the-counter or herbal supplement drugs?
*
Yes
No
If "Yes" Please List
*
Check all of the following that apply
Abnormal Bleeding
Alcohol / Drug Abuse
Arthritis
Blood Transfusion
Colitis
Difficulty Breathing
Fainting Spells / Dizziness
Glaucoma
Heart Surgery
High Blood Pressure
Recent Weight Loss
Shingles
Stomach Trouble / Ulcers
Tuberculosis (TB)
History of taking Bisphosphonates
Smoke or use tobacco
Have mouth sores / lumps
TMJ Jaw pain/clicking/popping
Have a history of orthodontics (braces)
Acid Reflux
Allergies / Hay Fever
Artificial bones/joints/valves
Cancer / Chemotherapy
Congenital Heart Defect
Emphysema
Frequent Headaches
Heart Attack
Heart Valve Replacement
Psychiatric Problems
Rheumatic / Scarlet Fever
Sickle Cell Disease / Traits
Stroke
Venereal Disease (STD)
History of taking Boniva / Fosamax
Dry mouth
Bite your lips or cheeks
Snore
Clench / Grind Teeth
Aids/HIV
Anemia
Asthma
Chest Pains
Diabetes
Epilepsy
Frequently Tired
Heart Murmur
Hepatitis A, B, C
Radiation Treatment
Seizures
Sinus Problems
Thyroid Disease
History of taking Fen-Phen / Redux
Daily Aspirin
Have pain or sensitive teeth
Bleed upon brushing / flossing
Wear dentures / partials
Previous head/neck/jaw injuries
Other
Are you pregnant?
*
Yes
No
Nursing
*
Yes
No
List other medical conditions
*
Allergies
penicillin
latex
Aspirin
codeine (or other narcotics)
local Anesthesia
metal/costume jewelry
Other
Please list other allergies
*
Authorization & Release
*
I, attest that I understand and have answered all the above questions honestly and completely. I understand that the doctor is basing the treatment on this information. I authorize the release of information to insurance carriers and other health professionals who are involved in my care. I assign my insurance benefits to Star Care Dental unless otherwise noted.
Acknowledgment of Receipt of Notice of Privacy Practices
*
I acknowledge that a copy of the Provider’s Notice of Privacy Practices is available anytime on our website or a copy is available at my request.
Signature
*
*
By clicking submit, I agree that this signature is the electronic representative of my personal signature for use on all documents including legally binding documents in this office – in just the same way as a pen-and-paper signature.
Name
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
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