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Patient Registration

It is the goal of our office to provide you a quality of care of the highest standards. Your comfort during your treatment is important to us. Please fill out this with the best of your knowledge.

Patient Information

Do you have a "Durable Power of Attorney" or "Living Will" for medical decisions:

Has the Durable Power of Attorney or Guardianship been activated by a physician?:

If activated, a guardian or DPOA representative needs to be present for the appointment as well as the paperwork is required by our office prior to your scheduled visit - please call our office with any questions.


Gender:
Marital Status:
Date of Birth:
State:

 

If patient is a minor or is under guardianship:

 

Please List Your:

 

Insurance Information

Primary Carrier

Date of Birth:

 

Secondary Carrier

Date of Birth:

 

To minimize our fees to you for treatment, we expect payment at the time of treatment. Patients with insurances may be requested to make co-payment at the time of treatment. Visa, MasterCard, and Discover are accepted. These policies will be adhered to unless arrangements with our office are made in advance of treatment.

 

General Health Information

A detailed health history is invaluable for helping us treat you safely and effectively. Please be very accurate in the following sections. The confidentiality of this medical record is assured.

 


Are you in good general health?:





Are you allergic to latex?

Have you ever had heart problems?

Have you ever had a heart attack?

Have you ever been told that you have a heart murmur?

Do you have an artificial heart valve?

Have you ever been told that you have a heart defect or congenital heart problems?

Have you had a heart infection?

Do you get chest pain or angina?

Do you have jaw problems or a history of TMJ?

Do your ankles swell?

Are you pregnant or nursing?

Do you have a difficulty of breathing or shortness of breath?

Have you ever had asthma attacks?

Do you have a cough?

How much do you smoke?

Have you ever had hepatitis?

Do you have AIDS, or have you been exposed to AIDS?

Do you drink alcoholic beverages?

Do you have a history of substance abuse?

Do you have problems with ulcers?

Do you have digestion problems?

Do you have difficulty urinating?

Do you urinate more that six times each day?

Have you ever had seizures or convulsions?

Have you ever had a stroke?

Are you diabetic?

Do you get cold sores?

Do you have any bleeding problems?

Have you been anemic recently?

Have you ever had cancer or radiation therapy?

Do you have a prosthetic or artificial joints?

Have you in the past taken, or are you currently taking any medication for osteoporosis?

The following fields are required:

Is the information provided above true to the best of your knowledge?

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