wightmanfamilydental.com - Adult Registration Form Patient Information * Patient Name: (Required) Gender: Male Female Social Security Number: Birth Date: Age: Home Address: City: State: Zip: Primary Phone Number: Phone Type home cell OK to leave message? Yes No * E-mail: (Required) Employer's Name: Occupation: Spouse / Partner Information Spouse/Partner's Name: Marital Status: Single Married Divorced Widowed Significant Other Social Security Number: Birth Date: Driver's License Number: Address (if different than patient): City: State: Zip: Primary Phone: Phone Type: home cell Secondary Phone: Phone Type: home cell Emergency Contact Information Emergency Contact's Name: Phone Number: Relation to Patient: Address: City: State: Zip: Person(s) OK to release appointment or medically-related information to: Relation to Patient: Insurance Information Primary Insurance Primary Insurance Company: Phone Number: Group Number: Policy Number: Member ID Number: Co-pay (if known): Deductible (if known): Policy Holder's Name: Relation to Patient: Policy Holder's SSN: Policy Holder's Date of Birth: Employer: Work Phone Number: Secondary Insurance Secondary Insurance Company: Phone Number: Group Number: Policy Number: Member ID Number: Co-pay (if known): Deductible (if known): Policy Holder's Name: Relation to Patient: Policy Holder's SSN: Policy Holder's Date of Birth: Employer: Work Phone Number: Dental History How did you hear about our practice? Ad Internet Family/Friend Physician Other Name of person referring (if applicable): Have your tonsils or adenoids been removed? Yes No Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)? Yes No Do you have any missing or extra permanent teeth? Yes No Have you ever had an injury to (select all that apply): Teeth Mouth Chin Do you have speech problems? Yes No If so, explain: Do your gums bleed? Yes No Do you smoke? Yes No Do you like your smile? Yes No Do you currently or have you ever had any of the following habits (check all that apply): Clenching/Grinding Teeth Lip Sucking/Biting Mouth Breathing Nail Biting Thumb/Finger Sucking Chewing/Eating Problem Medical History Are you currently being treated by a physician? Yes No Reason: Physician: Last Visit: Phone: Do you have any allergies/sensitivities to medications or latex? Yes No If yes, please list: Are you currently taking any prescription or over-the-counter medications? Yes No If yes, please list with the dosage: Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)? Yes No Have you had any serious illnesses or operations? If yes, describe: Have you ever had a blood transfusion? Yes No If yes, give approximate dates: (Women) Are you pregnant? Yes No Nursing? Yes No Taking birth control pills? Yes No Check if you have ever had any of the following: Anemia Arthritis, Rheumatism Artificial Heart Valves Artificial Joints Asthma Back Problems Blood Disease Cancer Chemical Dependency Chemotherapy Circulatory Problems Cortisone Treatments Cough, Persistent Coughing Blood Diabetes Epilepsy Fainting Glaucoma Headaches Heart Murmur Heart Problems Hemophilia Hepatitis High Blood Pressure HIV/AIDS Jaw Pain Kidney Disease Liver Disease Mitral Valve Prolapse Pacemaker Radiation Treatment Respiratory Disease Rheumatic Fever Scarlet Fever Shortness of Breath Skin Rash Stroke Swelling of Feet or Ankles Thyroid Problems Tobacco Habit Tonsilitis Tuberculosis Ulcer Venereal Disease (STD) Authorization I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained. Submitted by: Date:
