Patient Form

Please fill out the registration form to the best of your knowledge.

All patient information is confidential


PATIENT INFORMATION
Mr. Mrs. Ms. Miss. Dr.
Patient First Name: M.I. Last Name:
Address: City State: Zip
Home Tel: Bus. Tel: Ext. Email:
Date of Birth (M/D/Y): Age: Sex: Male Female
Social Security: Driver License #:
Status: Married Divorced Legally Separated Widow Single Student
Referred By:
Dentist:
Physician:
Orthodontist:
Have you ever been a patient in our practice: Yes No

IN CASE OF ANY EMERGENCY, CONTACT:
Name: Relationship:
Telephone #: Work #:

Have you seen your medical doctor in the past year and why? Yes No
Why?
Have you had anything to during in the past six hours? Yes No
Do you have any allergies to medications? Yes No
If yes, list here:
Are you currently taking any medications? Yes No
If yes, list here:

Have You Had or Do You
Currently Have
Yes No Have You Had or Do You
Currently Have
Yes No
Rheumatic fever? Heart murmur?
Damaged heart valves/
mitral valve prolapse?
Heart attack(s)?
Diabetes? High blood pressure?
Prolonged Bleeding? AIDS/HIV
Chest pain, angina? Kidney Disease?
Blood Disease Asthma?
Tuberculosis? Contact lenses?
Bronchitis, chronic cough? Stroke?
Cortisone? Liver Disease?
Cancer? Porphyria?
Chemotherapy? Radiation?
Hepatitis? Thyroid trouble?
Please list any major operations/surgeries:
Are you a smoker? Yes No
Do you have an alcohol/drug dependency? Yes No
Do you take blood - thinners (anti-coagulants) Yes No

WOMEN
Do you take birth control pills? Yes No
Are you breast-feeding/nursing? Yes No
Are you pregnant? Yes No

INSURANCE INFORMATION

Patient or guardian that is accompanying is responsible for bringing their own insurance information and paying any balances or copayments that are due at the time of the visit.

Is the Patient a full-time student? Yes No
If yes, what school?
Location of School:

 

Primary Dental Carrier

 

Insurance Company Name:

Group No.: Group Name:
Employer:
Policy Holder's Name: Relation to Patient:
Policy Holder's Date of Birth (MM/DD/YY):
Policy Holder's ID/Social Security#:

 

Primary Medical Carrier

 

Insurance Company Name:

Group No.: Group Name:
Employer:
Policy Holder's Name: Relation to Patient:
Policy Holder's Date of Birth (MM/DD/YY):
Policy Holder's ID/Social Security#:

 

Secondary Dental Carrier

 

Insurance Company Name:

Group No.: Group Name:
Employer:
Policy Holder's Name: Relation to Patient:
Policy Holder's Date of Birth (MM/DD/YY):
Policy Holder's ID/Social Security#:

 

Secondary Medical Carrier

 

Insurance Company Name:

Group No.: Group Name:
Employer:
Policy Holder's Name: Relation to Patient:
Policy Holder's Date of Birth (MM/DD/YY):
Policy Holder's ID/Social Security#:

I authorize the release of any medical information necessary to process this claim and request payment of benefits directly to Implants & Oral Surgery of Utah for services rendered.
I understand that the provider's charge may exceed my insurance company's payment. I will be financially responsible for any unpaid balances.
I understand that there will be a returned check fee charged to my account should any personal check used for payment on my account return for any reason.

(PLEASE READ THE ABOVE INFORMATION BEFORE SUBMITTING)

Please print this form and fax it to 914-232-9599