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Patient Information:

Personal Information
 
481 S 8th Ave Brighton, CO 80601
jeffpoulson@poulsonfamilydental.com

Patient Registration Form
 
Responsible Party
First Name____________ Preferred____________ Initial___________    Last Name______________
Patient
First Name____________ Preferred____________ Initial___________    Last Name______________


Addres__________ City___________ State______________ Zip_________________
Home Phone____________________ Work__________________ Cell__________________
Birthday______________

Social Security
Email Address      
Emergency Contact
 
check if you would like to receive email reminders and promotions
 
Name_________________ Relation___________________ Phone number______________
Phone number          

Employer Information of Subscriber Insurance
Employers Name_________________ Phone number_________________ Address_________________
City_________________ State_________________ Zip_________________  
Full time student   Yes    No    Where_________________________________    

Insurance Information (If you do not know the following information please contact your insurance company by phone or internet.)
Subscribers Name
Social Security
DOB
Insurance Company
Plan Name
Phone number     Address                                             City                    State                Zip
Group Number                Policy Number                        Payor ID/Number
Individual Deductible _$                  Individual yearly max _$        Renewal date     /        /        

Secondary Insurance Information
Subscribers Nam
Social Security
Insurance Company
Plan Name
Address                                         City            State                        Zip
Group Number                Policy Number                    Payor ID/Number        
Individual Deductible _$                     Individual yearly max _$    Renewal date             /    /    

Referral source
How did you hear about us?     

Dental insurance plans do not normally provide full coverage of your dental bill. Your dental coverage is a contract between you and your insurance company, and while we will cooperate to the fullest in expediting your claim, you are ultimately responsible for your account.  Your portion of the bill will be due at time of service.

If your insurance has not paid within 60 days from the date from the date of service, we will look to you for prompt payment of the account. All costs for collection of the account, should collection procedures or small claims court become necessary, will be passed on to the patient and/or the responsible party.

I understand that, due to any false information, I will be subject to criminal prosecution

Signature__________________________________ Date_______________________
 

 

Medical History

Patient Name ___________________________________ DOB __________________
Physician’s Name:    Address:    Phone:      

Are you having pain or discomfort at this time?    Y    N    Please explain:      
Do you feel very nervous about having dental treatment?    Y    N    Please explain:     
Have you ever had a bad experience in a dental office?    Y    N    Please explain:     
Have you been a patient in the hospital during the past two years?   Y    N    Please explain:        Are you under the care of a medical doctor?    Y      N      Please explain:      Are you taking any prescription or over-the-counter medications?     Y     N     Please list:       


Have you had any excessive bleeding requiring special treatment? ?    Y    N    Please list:       
Are you ALLERGIC or sensitive to any of the following:
   Aspirin Iodine
Penicillin       Codeine         Egg
    Latex        Metal
     Sulfa      Other:  Please list:         Hay/Seasonal  Nut
Circle any of the following, which y
Abnormal Bleeding…………..    ou hav
Yes      e ha
No    d or have at present:
Emphysema……………...    
Yes    
No    
Liver Disease…………….    
Yes    
No
AIDS / HIV+…………..……..    Yes    No    Epilepsy or seizures……..    Yes    No    Mental Disorders………...    Yes    No
Anemia…………..……………    Yes    No    Head Injuries…………….    Yes    No    Nervous Disorders……….    Yes    No
Arteriosclerosis……………….    Yes    No    Headaches (Frequent)…...    Yes    No    Pacemaker……………….    Yes    No
Arthritis……………………….    Yes    No    Heart Disease……………    Yes    No    Radiation Treatment……..    Yes    No
Artificial Joints/Valve………...    Yes    No    Heart Murmur…………...    Yes    No    Respiratory Problems……    Yes    No
Asthma………………………..    Yes    No    Hemophilia………………    Yes    No    Rheumatic Fever………...    Yes    No
Blood Disease/Transfusion…...    Yes    No    Hepatitis A………………    Yes    No    Rheumatism……………..    Yes    No
Bruise Easily………………….    Yes    No    Hepatitis B………………    Yes    No    Sinus Problems………….    Yes    No
Cancer/Chemotherapy………..    Yes    No    Hepatitis C………………    Yes    No    Stomach Problems………    Yes    No
Congestive Heart Failure……..    Yes    No    Hyper/Hypothyrodism….    Yes    No    Stroke……………………    Yes    No
Cortisone Medication…………    Yes    No    Hypertension…………….    Yes    No    Tuberculosis…………….    Yes    No
Diabetes……………………….    Yes    No    Hypotension……………..    Yes    No    Tumors…………………..    Yes    No
Drug Addiction……………….    Yes    No    Kidney Disease………….    Yes    No    Ulcers……………………    Yes    No
Women:                                
Are you pregnant now?
Are you taking birth control pills?    Y    N
Y    
N    What Week: ____________________    Are you nursing?
(Antibiotic medications can reduce birth control effectiveness)    Y    N
Do you anticipate becoming pregnant?    Y    N

When you walk up stairs or take a walk, do you ever stop because of chest pain, shortness of breath, or fatigue? …………    Y    N
Do your ankles swell during the day?  …………..…………..…………..…………..…………..…………..…………..………    Y    N
Do you use more than 2 pillows to sleep?  …………..…………..…………..…………..…………..…………..……………..    Y    N
Have you lost or gained more than 10 pounds in the past year?  …………..…………..…………..…………..………………    Y    N
Do you ever wake up from sleep with short of breath?  …………..…………..…………..…………..…………..……………    Y    N
Are you on a special diet?  …………..…………..…………..…………..…………..…………..…………..…………………..    Y    N
Do you have any disease, conditions, or problems not listed? …………..…………..…………..…………..………………...    Y    N
If yes, please list:     
Do you use any of the following products?  (Please circle)
Cigarettes    Alcohol    Cigars    Chewing Tobacco    Pipe    Snuff

When was your last dental cleaning and exam?  _________________________________  Where?_______________________________________________________
Is there anything you would like to change about your smile?   

 

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