The Patient Pre-Registration Form is provided for your convenience.  The information gathered here will be emailed to our office for entry into our medical computers.  You will only need to review and sign the final form when you come in for your appointment.  Please answer the requested information as completely as possible.  If you have any questions regarding this form, please contact us.

PATIENT INFORMATION (Confidential)

Date:
Full Name:    Birthdate:   SSN#:
Address:    City:   Home Phone:
Check Appropriate Box: Minor   Single   Married   Divorced   Widowed   Separated
If Student, Name of School / College:      City:   State   F-Time  P- Time
Patient's or Parent's Employer:  Work Phone:
Business Address:   City:   State:   Zip:
Spouse or Parent's Name:   Employer:   Work Phone:
Who May We Thank For Referring You?
Person to Contact in Case of Emergency:   Phone:

RESPONSIBLE PARTY

Name of Person Responsible for this Account:  Relationship to Patient:
Address:   Home Phone:
Driver's Lic.#:   Birth date:  Financial Institution:
Employer:   Work Phone:   SSN#:
Is this Person Currently a Patient in our Office? Yes   No
For your convenience, we offer the following methods of payment.  Please check the option your prefer.
Payment in full at each appointment.
Cash     Personal Check     Credit Card:  VISA   MasterCard     I wish to discuss the office's payment policy

INSURANCE INFORMATION

Name of Insured:   Relationship to Patient:
Birth date:   SSN#:   Date Employed:
Name of Employer:   Union or Local#:  Work Phone:
Address of Employer:   City:   State:   Zip:
Insurance Company:   Group#:   Policy/ID#:
Ins. Co. Address:   City:   State:   Zip:
How Much is your Deductible?   How Much Have You Used?  Max. Annual Benefit:
DO YOU HAVE ANY ADDITIONAL INSURANCE?   Yes   No


PATIENT MEDICAL HISTORY

Physician:   Office Phone:   Date of Last Exam:

  YES NO
1. Are you under medical treatment now?
2. Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years?
If yes, please explain:
3. Are you taking any medication(s) including non-prescription medicine?
If yes, please list:
4. Have you ever taken Phen-Fen/Redux?
5. Do you use tobacco?
6. Do you use controlled substances?

7. Do you have or have you had any of the following YES NO
High Blood Pressure
Heart Attack
Rheumatic Fever
Asthma
Epilepsy / Seizures
Leukemia
Diabetes
Kidney Diseases
AIDS or HIV Infection
Thyroid Problem
Heart Disease
Cardiac Pacemaker
Heart Murmur
Angina
Anemia
Emphysema
Cancer
Arthritis
Joint Replacements or Implant
Hepatitis / Jaundice
Sexually Transmitted Disease
Stomach Troubles / Ulcers
Chest Pains
Stroke
Hay Fever / Allergies
Tuberculosis
Radiation Therapy
Liver Disease
Respiratory Problems
Mitral Valve Prolapse
Other:

PATIENT DENTAL HISTORY

Name of Previous Dentist and Location   Date of Last Exam:

  YES NO
1. Do your gums bleed while brushing or flossing?
2. Are your teeth sensitive to hot or cold liquids/foods?
3. Are your teeth sensitive to sweet or sour liquids/foods?
4. Do you feel pain to any of your teeth?
5. Do you have any sores or lumps in or near your mouth?
6. Have you had any head, neck or jaw injuries?
7. Have you ever experienced any of the following problems in your jaw?    
          Clicking?
          Pain (joint, ear, side of face)?
          Difficulty in opening or closing?
          Difficulty in chewing?
8. Do you have frequent headaches?
9. Do you clench or grind your teeth?
10. Do you bite your lips or cheeks frequently?
11. Have you ever had any difficult extractions in the past?
12. Have you ever had any prolonged bleeding following extractions?
13. Have you and any orthodontic treatment?
14. Do you wear dentures or partials?
      If yes, date of placement:
15. Have you ever received oral hygiene instructions regarding the care of your teeth and gums?
16. Do you like your smile?

8. Are you allergic to or have you had any reactions to the following?

  YES NO
A. Local Anesthetics (e.g. Novocain)
B. Penicillin or other Antibiotics
C. Sulfa Drugs
D. Barbiturates
E. Sedatives
F. Iodine
G. Aspirin
H. Any Metals (e.g. nickel, mercury, etc)
I. Latex Rubber

9. Women Only:

A.  Are you pregnant or think you may be pregnant?
B.  Are you nursing?
C.  Are you taking oral contraceptives?

AUTHORIZATION AND RELEASE
(To be signed when patient comes to office)

I certify that I have read and understand the above information to the best of my knowledge.  The above questions have been accurately answered.  I understand that providing incorrect information can be dangerous to my health.  I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such Dental care to third party payers and/or health practitioners.  I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me.  I understand that my dental insurance carrier may pay less than the actual bill for services.  I agree to be responsible for payment of all services rendered on my behalf or my dependents.

          

Walnut Ridge Family Dental v 15672 West Maple Rd v Omaha, NE  68116
PHONE: (402) 965-3603      v       EMAIL: mailto:drdka@walnutridgedental.com