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Patterson Dental Lab
Welcome
History
Services
Hours & Location
Staff
Payment Options
Contact Us
Image Gallery
Patterson Dental Lab
New Patient Registration Form
Patient Information
Name
*
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Home Phone
(###)
###
####
Work Phone
(###)
###
####
Cell Phone
(###)
###
####
Email Address
*
Email Opt-In
I would like to receive correspondences via e-mail.
Sex
Male
Female
Marital Status
Married
Single
Divorced
Separated
Widowed
Birth Date
MM
DD
YYYY
Age
Social Security Number
Drivers License Number
Section 2
Employment Status
Full-Time
Part-Time
Retired
Student Status
Full-Time
Part-Time
Medicaid ID
Employer ID
Carrier ID
Preferred Dentist
Preferred Pharmacy
Preferred Hygienist
Primary Insurance Information
Name of Insured
First Name
Last Name
Relationship to Insured
Self
Spouse
Child
Other
Insured Social Security Number
Insured Birth Date
MM
DD
YYYY
Employer
Insurance Company
Insurance Company Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Secondary Insurance Information
Name of Insured
First Name
Last Name
Insured Social Security Number
Insured Birth Date
MM
DD
YYYY
Employer
Insurance Company
Insurance Company Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Medical History
Although dental personnel primarily treat the area in and around the mouth, your mouth is 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 truthfully.
Are you under a physician's care now?
Yes
No
Have you ever been hospitalized or had a 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
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates
Yes
No
Are you on a special diet?
Yes
No
Do you use (smoke, dip, or chew) tobacco?
Yes
No
If you answered "yes" to any of the above medical history questions please explain:
Women: Are you...
Pregnant/Trying to get pregnant
Nursing
Taking oral contraceptives
Are you allergic to any of the following?
Aspirin
Penicillin
Codeine
Acrylic
Metal
Latex
Sulfa Drugs
Local Anesthetics
Other
Do you use controlled substances?
A controlled substance is generally defined as a drug or chemical whose manufacture, possession, or use is regulated by the government (i.e. prescription medications and illegal drugs).
Yes
No
Do you have, or have you had, any of the following?
Thank you!
