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Patient Registration Form Surgery Information FAQ Financial Arrangements Ask the Doctor Form

privacy & disclaimer policy © Copyright 2000-2008 Thomas W. Hebda, D.D.S. all rights reserved

PATIENT REGISTRATION FORM

Please fill out and submit the following form prior to your first scheduled appointment.

Last Name	First Name	Middle Name
			Miss Ms. Mrs. Mr. Dr. Rev.

Telephone	Cell Phone

Residence Address

City	State	Zip

Occupation	Employer/School	Work Phone

Parent/Guardian (if minor)	Home Phone Number

Address

Occupation	Employer/School	Work Phone

INSURANCE INFORMATION:

Dental:	Insurance Co.	Subscriber
	ID Number	Group #
Secondary Dental:	Insurance Co.	Subscriber
	ID Number	Group #
Medical:	Insurance Co.	Subscriber
	ID Number	Group #
Secondary Medical:	Insurance Co.	Subscriber
	ID Number	Group #
Employer

IN CASE OF EMERGENCY:

Name	Relationship

Address	Home Phone #:

City	Zip	Work Phone #:

Name of person or doctor who referred you to this office

Have you or has any member of your family ever been a patient in our office prior to today?
No Yes

If yes, name of patient and approximate date of treatment:

MEDICAL AND DENTAL HISTORY

Physicians Name:	Date of Last Physical Exam:
Present Complaint or Problem (max 150 characters):

HEART PROBLEMS	Yes	No
MURMUR/VALVULAR DEFECTS	Yes	No
RHEUMATIC FEVER	Yes	No
CONGENITAL HEART DISEASE	Yes	No
HEART ATTACK	Yes	No
CHEST PAIN	Yes	No
HIGH BLOOD PRESSURE	Yes	No
FREQUENTLY SWOLLEN ANKLES	Yes	No
SHORTNESS OF BREATH	Yes	No
LUNG DISEASE/PERSISTENT COUGH	Yes	No
PNEUMONIA	Yes	No
SMOKE OR CHEW TOBACCO	Yes	No
ALCOHOL OR RECREATIONAL DRUGS	Yes	No
ASTHMA, HAY FEVER OR ALLERGIES	Yes	No
STROKE OR TIA	Yes	No
THYROID DISEASE	Yes	No
FREQUENT SORES IN MOUTH	Yes	No
GLAUCOMA	Yes	No
FAINTING SPELLS	Yes	No
EPILEPSY, CONVULSIONS, SEIZURES	Yes	No
DIABETES	Yes	No
LIVER DISEASE (HEPATITIS /JAUNDICE/CIRRHOSIS)	Yes	No
KIDNEY DISEASE	Yes	No
STOMACH ULCER/GASTRO/ESOPHAGEAL REFLUX	Yes	No
VENEREAL DISEASE	Yes	No
BLEEDING PROBLEMS/ANEMIA/BLOOD THINNER BRUISING	Yes	No
ARTHRITIS	Yes	No
REACTION TO ANESTHESIA (ANY RELATIVES)	Yes	No
RADIATION THERAPY	Yes	No
MALIGNANCIES	Yes	No
ARE YOU PREGNANT/BREAST FEEDING	Yes	No
DO YOU WEAR CONTACT LENSES	Yes	No
SINUS OR NASAL PROBLEM	Yes	No
DO YOU PLAY A WIND INSTRUMENT	Yes	No

Are you allergic to latex(rubber gloves, balloons, elastic)? Yes No
Have you ever been hospitalized or had previous surgeries? Yes No
If yes, explain
Are you allergic to or had a reaction to drugs/medications (penicillin, sulfa)? Yes No
If yes, explain
Are you taking any pills, medications, herbal and/or dietary supplements Yes No
If so, please list here
Are you taking or have you taken Fosamax, Zometa, Boniva, Actonel or Reclast? Yes No
Are you in Good Health? Yes No
Have there been any changes in your health in the past year? Yes No
Are you currently being treated for any communicable diseases? Yes No
Please describe any current medical treatment, impending operations or any other medical or dental information that my possibly affect your treatment: (150 char max)
Do you wish to talk with the Doctor privately? Yes No
Dentist Name:
Date of last dental exam:
Any complications with dental treatment? Yes No
If yes, explain
Do you clench or grind your teeth? Yes No
Any pain in or around the ears? Yes No
Does your jaw pop, click or grind? Yes No
If so, please describe
Additional comments (200 character max)

The form may take a short while to submit, please be patient and only click the Submit button one time.