endodontics limited, p.c. registration formphen fen diet artificial joints overactive thyroid...
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PLEASE PRINT Date ________________________ SINGLE MARRIED
Name______________________________________________________Sex: M F WIDOWED DIVORCED
Address_______________________________________________________________ SEPARATED
City ______________________________________________________State ___________________ Zip Code ______________
Home Phone ___________________________ Mobile Phone ___________________________ Birthdate _________________
Email ____________________________ Bus. Phone __________________________Soc. Sec. # ________________________
Employed By _______________________________________________________ Medical Doctor's Name
Occupation _________________________________________________________ ___________________________________
Referred By _________________________________________________________ Dentist's Name
Name of Parent / Spouse _____________________________________________ ___________________________________
Person Responsible for Payment If other than Above ______________________________________
Relationship to Patient ( ) Spouse ( ) Parent or Guardian Does This Person Reside in the Same Household? Yes No
Address _________________________________________________________________________________________________
City _____________________________________________________State ____________ Zip Code ______________________
SS # __________________________ Home Phone ______ ___________________ Work Phone______ ________________
Employer’s Name __________________________________________________ Occupation ___________________________
Emergency Contact _________________________________________ Phone Number _______________________________
ENDODONTICS LIMITED, P.C.REGISTRATION FORM
HEALTH QUESTIONS
Is your general health good? ...................................................................................................................... Yes No
Are you under a physician’s care now? ..................................................................................................... Yes No
Heart MurmurHeart TroubleMitral Valve ProlapseHigh Blood PressurePacemaker for HeartPhen Fen DietArtificial Joints
Overactive ThyroidUnderactive ThyroidHerpesAIDS/HIVUlcerDiabetesNervous Disorder
AsthmaBleeding DisordersSeizuresOsteoporosisTuberculosisCancer
Rheumatic FeverHepatitisCurrently PregnantArthritisAutoimmune DiseaseLatex Allergy
Yes No Yes No Yes No Yes No
Have you ever had an allergy or unusual reaction to any drug, general or local anesthetic? (If yes, list) Yes No
Is there any other information about your health that should be known? ................................................ Yes No
List all medications that you presently take and why:
Drug ___________________ Condition ___________________ Drug ___________________ Condition ___________________
Drug ___________________ Condition ___________________ Drug ___________________ Condition ___________________
Drug ___________________ Condition ___________________ Drug ___________________ Condition ___________________
I have been given a copy of “Important Facts About Root Canal Therapy” and have been advised to read it and ask any questions regarding the contents that I do not understand.
Signed ______________________________________________________ Dr.________________
If you have Dental Insurance Turn to Back of this Page to Continue
If you have dental insurance fill out the following:
What amount do you think is covered by your insurance towards root canal therapy?
Don’t Know 100% 80% 50% 25% Other
Please check one of the following:
I plan to pay the doctor directly and I will be reimbursed by my insurance company.
If possible I would have the insurance company pay the doctor directly and I understand that I am responsible for any amount not covered by insurance.
My Dental Insurance:
( ) Is provided by my employer:
Name of insurance company or Union _________________________________________
Number on Insurance Card __________________________________________________
( ) Is provided by my spouse’s/parent’s employer:
Spouse/Parent Name ___________________________________________________________________________
Spouse/Parent works for ____________________________ Ins. Co. _____________________________________
Spouse/Parent SS# _______________________________ Spouse/Parent B’day________________Sex: M F
( ) I purchase my own dental insurance:
Insurance Co. _______________________________________ Address __________________________________
NOTE:
Due to the constantly changing insurance rules and regulations, benefits and deductibles, we areonly able to approximate your insurance balance. If your insurance pays more than expected youwill be credited the difference. If your insurance company pays less than expected you will be billedthe difference. Final responsibility for payment rests with the person responsible for your account.
I authorize the doctors to release any information necessary to process my claim.
Date ____________ Signature ________________________________ Relationship to Patient _____________
If patient is covered by more than one insurance fill out.
Secondary Dental Insurance
Employee’s Name _______________________________________________________ Birthdate _______________Sex: M F
SS # or Subscriber Number Shown on Card _________________________________________________________________
Employer’s Name _________________________________________________________________________________________
Insurance Company ____________________________Address ___________________________________________________
Relationship to Patient: ( ) Self ( ) Spouse ( ) Parent/Guardian Group # ______________________________
FORM 100680 ENDODONTICS LIMITED, P.C. ITEM 40684