Hempstead NY Family Dentists in Nassau County Root Canals Long Island Fillings Dentistry

Gentle Dental

Terry E. Grant, DMD

Patient Registration And Medical History

Date:

Home phone*:

Patient Last Name*:

First Name*:

Middle Initial:

Preferred Name:

Street Address*:

City*:

State:

Zip*:

E-mail*:

Cell Phone:

Sex:

M F

Age:

Birth date:

Minor Married Widowed Single Separated Divorced Partnered for years

Employer / School:

Occupation:

Employer / School address:

Employer / School phone:

Spouse / Parent Name:

Spouse / Parent Birth Date:

Spouse / Parent Employed by:

Occupation:

Business Address:

Business Phone:

Who is responsible for this account?

Relationship to patient:

Social security #:

Spouse / Parent Social security #:

Name of Dental Insurance Company:

Group#:

In case of emergency, who should be notified:

Phone:

Whom may we thank for referring you?

Medical History

Physician's Name:

Date of Last Physical:

Have you ever had any of the following? (check boxes that apply):

Allergies
Arthritis
Artificial Heart Valves, or Joints, Screws
Back Problems
Bleeding Abnormally
Blood Disease
Cancer
Chemical Dependency
Chronic Diarrhea
Circulatory Problems
Congenital Hearts Lesions
Diabetes

Epilepsy
Headaches
Heart Murmur
Heart Problems
Hemophilia
Hepatitis, Jaundice, or Liver Disease
Hernia Repair
High Blood Pressure
HIV/AIDS
Low Blood Pressure
Mitral Valve Prolapse
Nervous Problems

Pace Maker
Psychiatric Care
Radiation Treatment
Recent Weight Loss
Respiratory Disease
Rheumatic Fever
Sinus Problems
Special Diet
Stroke
Swollen Neck Glands
Ulcer
Venereal Disease

Do you have any drug related allergies or have you ever had an adverse reaction to any medication or anesthesia?

Yes No

If so, what

Have you ever responded adversely to medical or dental treatment?

Yes No

Are you taking any medication at this time?

Yes No

If so, what

Have you ever taken any of the group of drugs collectively referred to as "fen phen"? These include combination of Ionimin, Adipex, Fastin (brand names of Phentermine), Pondimin (Fenfluramine) and Redux (Dexfenfluramine)

Yes No

Are you under the care of a physician?

Yes No

If Yes, for what conditions?

If patient is a child, what is his/her weight?

(Women) Do you suspect that you are pregnant?

Yes No

If yes, Due date

Are you nursing?

Yes No

Taking birth control pills?

Yes No

Is there anything else we need to know about your medical history?

Medical History Update

Has there been any change in the patient's health since the last dental appointment?

Yes No

If Yes, for what conditions?

Is the patient taking any new medications?

Yes No

If yes, what?

Date

Patient signature

Certification

To the best of my knowledge the information provided on this form is complete and correct. I understand that it is my responsibility to inform my doctor, if my minor child ever has a change in health.

Minor / Child Consent

I am the parent, guardian or personal representative of and there are no court orders now in effect that prohibit me from signing this consent. I do hereby request and authorize the dental staff to perform necessary dental services for the child named above, including but not limited to x-rays, and administration of anesthetics, which are deemed advisable by my doctor, whether or not I am present when the treatment is rendered.

Insurance Assignment and Release

I certify that my dependent(s) is covered by insurance with . And assign directly to Dr. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or nor paid by insurance. I authorize the use of my signature on all insurance submissions.

The above named doctor may use my minor / child's health care information and may disclose such information to the above named Insurance Company (ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for the related services. This consent will end when the current treatment plan is completed or one year from the date signed below.

Financial Agreement

I acknowledge that payment is due at the time of treatment, unless other arrangements are made. I agree that parents, guardians or personal representatives are responsible for all fees and services rendered for treatment of a minor / child. I accept full financial responsibility for all charges for service or items provided to me or the patient. I understand that filling a claim with my insurance company does not relieve me from my responsibility for the payment of all charges.

Signature of Parent, Guardian or Personal Representative:

Date

Please print name of Parent, Guardian or Personal Representative:

Relationship to patient:

Place verification code in box: