Pa�ent Registra�on

Date:

Last Name First

Prefers to be called:

Address:

City State Zip

Home number:

Cell number:

Email:

Social Security no.

Account Informa on

PERSON FINANCIALLY RESPONSIBLE FOR ACCOUNT

Name:

Rela!onship to pa!ent:

Social Security no.

Address

City State Zip

Phone Number:

Email:

Dental Insurance Informa on

Ge ng to Know You

Birthday Age Male Female

Married Single Divorced Widowed

PRIMARY CARRIER

Insurance Company:

Group no.

Employer Name:

Policy Holder Name:

Date of Birth:

Rela!onship to pa!ent:

I.D. Number:

Policy Holders Social Security no.

SECONDARY CARRIER

Insurance Company:

Group no.

Employer Name:

Policy Holder Name:

Date of Birth:

Rela!onship to pa!ent:

I.D. Number:

Policy Holders Social Security no.

Is there another member of your family or rela!ve that is a

pa!ent at our o+ce?

Who referred you to our o+ce?

Emergency contact Name:

Phone Number:

Address

City State Zip

Dental History

Patient Name: What is the reason for your visit today?_______________________________________________________________________ Date of last dental visit_____________ Last Dental Cleaning______________ Last Full Mouth X-rays_____________________ Previous Dentisit’s Name______________________________Phone Number_________________________________________ Address_________________________________________________________________________________________________ How often do you have dental examinations?____________________________________________________ How often do you brush your teeth?________________________How often do you floss?_________________ What other dental aids do you use?(WaterPik, toothpick etc.)________________________________________ Are you using any prescription toothpaste or rinses?____________________________________________ Do you have any dental problems now? YES NO If yes please describe_______________________________________________________________________________________ Have you ever taken pre-medication prior to dental treatment? YES NO

Are any of your teeth sensitive to: Hot or Cold? YES NO

Sweets? YES NO Biting or Chewing? YES NO

Have you notice any mouth odors/bad taste? YES NO Do you frequently get cold sores, blisters

or any other lesions? YES NO

Do your gums bleed or hurt? YES NO Have your parents experienced gum disease

or tooth loss? YES NO Have you noticed any loose teeth or change

In your bite? YES NO Does food tend to become caught in between

Your teeth? YES NO

Do you: Clench or grind your teeth while awake or asleep? YES NO

Bite your lips or cheeks regularly? YES NO Hold foreign objects with your teeth? YES NO Mouth breath while awake or asleep? YES NO

Have tired jaws in the morning? YES NO Snore or have sleeping disorders? YES NO

Smoke/chew tobacco or E cigarette tobacco products? YES NO

Do you use marijuana? YES NO

Have you ever had: Orthodontic treatment? YES NO Do you wear retainers? YES NO

Oral Surgery? YES NO Periodontal treatment? YES NO

Your teeth ground or the bite adjusted? YES NO A bite plate or mouth guard? YES NO

A serious injury to the head or mouth? YES NO If so please describe, including cause______________ ____________________________________________

Have you ever experienced:

Clicking or popping of the jaw? YES NO Pain? (joint, ear, side of face) YES NO

Difficulty in opening or closing the mouth? YES NO Headaches, neckaches or shoulder aches? YES NO

Sore muscles? (neck, shoulders) YES NO

Are you satisfied with your teeth’s appearance? YES NO Would you like to keep your teeth all of your life? YES NO

Do you feel nervous about having dental treatment? YES NO If so what is your biggest concern?______________________

Have you ever had an upsetting dental experience? YES NO If yes, please describe________________________________ __________________________________________________

What is your beverage of choice throughout the day? __________________________________________________

*Is there anything else about having dental treatment that you would like us to know? YES NO If yes, please describe ________________________________________________________________________________________________________________________________________________________________________________________________________________________

Medical History

Patient Name: 1. Physician’s Name____________________________________Phone number( )______________________ ____

Have you had any medical care within the past two years? YES NO Describe if yes____________________________________________________________________________ ___

2. Have you taken any medication or drugs during the past two years? YES NO If yes, please list name and dosage___________________________________________________________ ____

3. Are you currently taking any medication? (Prescription or over the counter) YES NO If yes, please list name and dosage___________________________________________________________ ____

4. Have you ever taken a medication to prevent boneloss? such as Fosamax, Actonel, Boniva or other bisphosphonates? YES NO If yes, please list name, dosage and duration of time drug was taken_____________________________________

5. Are you aware of having an allergic or adverse reaction to any substance or medication? YES NO If yes, please specify____________________________________________________________________________

6. Have you ever been hospitalized? YES NO If yes, What for and when?________________________________ 7. Have you gained or lost more the 10 pounds in the last year? YES NO 8. Women: Are you pregnant or think you could be pregnant? YES NO 9. Please indicate if you have or have had any of the following conditions:

Heart (Surgery, Disease, Attack) YES NO

Chest Pain YES NO Congenital Heart Disease YES NO

Heart Murmur YES NO High/Low Blood Pressure YES NO

Mitral Valve Prolapse YES NO Artificial Heart Valve YES NO

Pacemaker YES NO Rheumatic Fever YES NO

Arthritis/Rheumatism YES NO Cortisone Medicine YES NO

Swollen Ankles YES NO Stroke YES NO

Diet (Special/Restricted) YES NO Artificial Joint (Hip, Knee, etc.) YES NO

Kidney Trouble YES NO Ulcers YES NO

Diabetes YES NO Thyroid problems YES NO

Glaucoma YES NO Contact Lenses YES NO

Emphysema YES NO Chronic Cough YES NO

Sleep Apnea YES NO

Tuberculosis YES NO Asthma YES NO

Hay Fever/Allergy/Hives YES NO Latex Sensitivity YES NO

Sinus Trouble YES NO Hepatitis A B C (circle) YES NO

Venereal Disease YES NO A.I.D.S./H.I.V. Positive YES NO

Cold sores/ Fever Blisters YES NO Blood Transfusion YES NO

Hemophilia YES NO Sickle Cell Disease YES NO

Bruise Easily YES NO Liver Disease/Yellow Jaundice YES NO

Neurological Disorders YES NO Epilepsy or Seizures YES NO

Fainting or Dizzy Spells YES NO Nervous/Anxious YES NO

Psychiatric/Psychological Care YES NO Radiation Therapy YES NO

Chemotherapy YES NO Tumors YES NO Cancer YES NO

If yes, location and date__________________

Do you have or have had any disease, condition or problem not listed above? YES NO If yes, please list:______________________________________________________________________________________ I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have

answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask

the respective health care provider, who may release such information to you. I will notify the doctor of any change in my

health or medications.

Patient Signature____________________________________________________________________ __________________ History Review: BP / Pulse: Dentist Signature:

General Dentistry Informed Consent

1. I hereby authorize Dr. Rosenthal or designated staff to take x-rays, study models, photographs, and other diagnostic aids

deemed appropriate by Doctor to make thorough diagnosis of dental needs.

2. Upon such diagnosis, I authorize Doctor to perform all recommended treatment mutually agreed upon by me and to

employ such assistance as required to provide proper care.

3. I agree to the use of anesthetic, sedatives and other medication as necessary for the completion of my treatment. I fully

understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any

possible complications.

4. I understand that antibiotics and analgesics and other medication can cause allergic reactions causing redness and swelling

of tissue, pain, itching, vomiting and/or anaphylactic shock. They may cause drowsiness and lack of awareness and

coordination which can be increased by using alcohol or other drugs. I understand and fully agree not to operate any

vehicle or hazardous device for 12 hrs or until fully recovered from the effect from anesthetic, medications, and/or drugs

that may have been given to me for my care. I understand that failure to take medications prescribed for me in the manner

prescribed may offer risk of continued or aggravated infection and pain and potential resistance to effective treatment of

my condition. I understand that antibiotics can reduce the effectiveness of oral contraceptives.

5. I understand that during treatment it may be necessary to change or add procedures because of condition found while

working on the teeth that were not discovered during examination, the most common being root canal therapy following

routine restorative procedures. I give my permission to the Dentist to make any/ all changes and additions as necessary for

the best treatment outcome.

6. I understand that symptoms of popping, clicking, locking and pain can intensify or develop in the joint of the lower jaw

(near the ear) subsequent to routine dental treatment where the mouth is held in an open position. Although symptoms of

TMD associated with dental treatment are usually transient in nature and well tolerated by most patients, I understand that

should the need of treatment arise, then I will be referred to a specialist for treatment, and the cost of which is my

responsibility.

7. I give consent to Dr. Rosenthal or designated staff’s use and disclosure of any oral, written or electronic health record that

are individually identifiable as mine for the purpose of carrying out my treatment, payment and health care operations. I

understand that only the minimum amount of information necessary to provide quality care will be used or disclosed and

that a notice fully outlining the protection of my personal health information is available.

8. I agree to be responsible for payment of all service rendered on my behalf or my dependents. I understand that payment is

due at the time of service unless other arrangements have been made. In the event payments are not received by agreed

upon dates, I understand that a 1-1/2% late charge(18%apr) may be added to my account. If required, I also understand a

check of my credit history may be made.

Patient’s Name(print) ____________________________________________________________ Date _________________________

Patient’s Signature ______________________________________________________________

Parent/Responsible Party’s Signature __________________________________________Relationship to Patient ________________

Marina Dental of Petaluma

Dr. Christopher Rosenthal DDS

765 Baywood Dr. suite 233

Petaluma, CA 94954

Patient Acknowledgement of Receipt of Dental Materials Fact Sheet

I _________________________________ acknowledge that I have received from Christopher

Rosenthal DDS a copy of the DMFS dated October 2001. If I decline to take a copy, I know that

one is always available in office to reference.

Signature________________________________________ Date _____________

The following document is the Dental Board of California’s DMFS. The department of consumer affairs has no position with respect to the

language of this DMFS and its linkage to the DCA website does not constitute an endorsement of the content of this document.

Acknowledgement or Receipt of Notice of HIPPA Privacy Practice

I_____________________________ have received a copy of this office’s notice of privacy

practice. If I decline to take a copy, I know that one is always available in office to reference.

Signature________________________________________ Date _____________