Patient Registration

We realize that it is a contradiction to politely say "Welcome" and to immediately request that you complete this form in the same sentence. However, it is vital that we obtain accurate, pertinent information in order to rener the best possible treatment. Therefore, we must ask your indulgence and request the inevitable.

Registration Form

Please complete the following form. All informtion will be kept strictly confidential. By the way, this is not an examination and no grade will be given, so if you have any questions or would like assistance, please ask. Thank-you and welcome to our office!

I. Personal Information

ID: Chart ID

First Name: Last Name: Middle Initial:

Patient is: Policy Holder Preferred Name:
Responsible Party

Responsible Party (If someone other than the patient):

First Name: Last Name: Middle Initial:

Address: Address 2 :

City: State: Zip: Pager:

Home Phone: Work Phone Ext: Cellular:

Birth Date: Soc Sec: Drivers Lic:

Responsible Party is also a Policy Holder for Patient Primary Insurance Policy Holder Secondary Insurance Policy Holder

Patient Information:

Address: Address 2 :

City: State: Zip: Pager:

Home Phone: Work Phone Ext: Cellular:

Sex: Female Male Marital Status: Married Single Divorced Separated Widowed

Birth Date: Age: Soc. Sec. Drivers Lic.

Email: I would like to receive correspondences via e-mail

Employment Status: Full Time Part Time Retired
Student Status: Full Time Part Time
Medicaid ID:	Pref Dentist:
Employer ID:	Pref. Pharmacy:
Carrier ID:	Pref. Hyg:

Referred By:
Previous Dentist:
Emergency Contact:
Emergency Contact #:
Credit Card:

Primary Insurance Information:

Name of Insured: Relationship to Insured: Self Spouse Child Other

Insured Soc. Sec. Insured Birth Date:

Employer:

Address:

Address 2:

City: State: Zip:

Ins.Company:

Address:

Address 2:

City: State: Zip:

Rem. Benefits: Rem. Deduct:

Secondary Insurance Information

Name of Insured: Relationship to Insured: Self Spouse Child Other

Insured Soc. Sec. Insured Birth Date:

Employer:

Address:

Address 2:

City: State: Zip:

Ins.Company:

Address:

Address 2:

City: State: Zip:

Rem. Benefits: Rem. Deduct:

Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Are you under a physician's care now?		Yes No
Have you ever been hospitalized or had major operation?		Yes No
Have you ever had a serious head or neck injury?		Yes No
Are you taking any medications, pills, or drugs?		Yes No
Do you take, or have you taken,Phen-Fen or Redux?		Yes No
Are you on a special diet?		Yes No
Do you use tobacco?		Yes No
Do you use controlled substances?		Yes No

If yes, please explain:

Women: Are you
Pregnant/Trying to get pregnant Yes No Taking oral contraceptives: Yes No Nursing? Yes No

Are you allergic to any of the following?
Aspirin Penicillin Codeine Acrylic Metal Latex Local Anesthetics Other If yes, please explain:

Do you have, or have you had, any of the following?

AIDS/HIV Positive	Yes No	Cortisone Medicine	Yes No	Hemophilia	Yes No	Renal Dialysis	Yes No
Alzheimer's Disease	Yes No	Diabetes	Yes No	Hepatitis A	Yes No	Rheumatic Fever	Yes No
Anaphytaxis	Yes No	Drug Addiction	Yes No	Hepatitis B or C	Yes No	Rheumatism	Yes No
Anemia	Yes No	Easily Winded	Yes No	Herpes	Yes No	Scarlet Fever	Yes No
Angina	Yes No	Emphysema	Yes No	High Blood Pressure	Yes No	Shingles	Yes No
Arthritis/Gouf	Yes No	Epilepsy or Seizures	Yes No	Hives or Rash	Yes No	Sickle Cell Disease	Yes No
Artificial Heart Valve	Yes No	Excessive Bleeding	Yes No	Hypoglycemia	Yes No	Sinus Trouble	Yes No
Artificial Joint	Yes No	Excessive Thirst	Yes No	Irregular Heartbeat	Yes No	Spina Bifida	Yes No
Asthma	Yes No	Fainting Spells/Dizzines	Yes No	Kidney Problems	Yes No	Stomach/Intestinal Disease	Yes No
Blood Disease	Yes No	Frequent Cough	Yes No	Leukemia	Yes No	Stroke	Yes No
Blood Transfusion	Yes No	Frequent Diarrhea	Yes No	Liver Disease	Yes No	Swelling of Limbs	Yes No
Breathing Problem	Yes No	Frequent Headaches	Yes No	Low Blood Pressure	Yes No	Thyroid Disease	Yes No
Bruise Easily	Yes No	Genital Herpes	Yes No	Lung Disease	Yes No	Tonsillitis	Yes No
Cancer	Yes No	Glaucoma	Yes No	Mitral Valve Prolapse	Yes No	Tuberculosis	Yes No
Chemotherapy	Yes No	Hay Fever	Yes No	Pain in Jaw Joints	Yes No	Tumor or Growths	Yes No
Chest Pains	Yes No	Heart Attack/Failure	Yes No	Parathyroid Disease	Yes No	Ulcers	Yes No
Cold Sores/Fever Blister	Yes No	Heart Murmur	Yes No	Psychiatric Care	Yes No	Venereal Disease	Yes No
Congenital Heart Disorder	Yes No	Heart Pace Maker	Yes No	Radiation Treatment	Yes No	Yellow Jaundice	Yes No
Convulsions	Yes No	Heart Trouble/Disease	Yes No	Recent Weight Loss	Yes No

Have you ever had any serious illness not listed below? Yes No If yes, please explain:

Comments:

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

Estrella Dental Clinic
AV. NINOS HEROES No. 995 between 3rd and 4th street.
Zona Centro, Tijuana, B.C., Mexico 22000
info@clinicadentalestrella.com

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Patient Registration

Registration Form

Medical History

Estrella Dental Clinic AV. NINOS HEROES No. 995 between 3rd and 4th street. Zona Centro, Tijuana, B.C., Mexico 22000 info@clinicadentalestrella.com

Estrella Dental Clinic
AV. NINOS HEROES No. 995 between 3rd and 4th street.
Zona Centro, Tijuana, B.C., Mexico 22000
info@clinicadentalestrella.com