THIS IS AN ONLINE FORM. DO NOT PRINT
THIS IS NOT A PRINTABLE FORM. PLEASE FILL ALL THE FIELDS AND HIT SUBMIT AT THE END.

PATIENT REGISTRATION AND MEDICAL HISTORY

Date
Name*
Marital Status
Address
How long at this address
Cell Phone*
Home Phone
Previous Address (if less than 3 yrs.)
Social Security #
Birth Date
Gender*
Employer
Occupation
# Yrs Employed
Spouse/Parent’s Name
Relationship to Patient
Employer
Occupation
# Yrs Employed
Social Security #
Birth Date
Cell Phone
In case of emergency, who should be notified?
Whom may we thank for referring you to our office?

Insurance Information

Policy Holder's name
and Soc. Sec. #
Insurance Company
Group No.
Union Local No.
Insurance ID No.
Policy Holder's Employer
Do you have dual coverage?
If yes:
Policy Holder's name
and Soc. Sec. #
Insurance Company
Group No.
Union Local No.
Insurance ID No.
Policy Holder's Employer

Medical History

Physician's Name
Date of Last Physical

Have you ever had any of the following? (Check boxes that apply):

Allergies

Arthritis

Artificial Heart Valves or Joints

Bleeding Abnormally

Cancer

Chemical Dependency

Chronic Diarrhea

Circulatory Problems

Congenital Heart Lesions

Diabetes

Epilepsy

Headaches

Heart Murmur

Hepatitis, Jaundice or Liver Disease

Hernia Repair

High Blood Pressure

HIV/AIDS

Low Blood Pressure

Mitral Valve Prolapsed

Nervous Problems

Pacemaker

Psychiatric Care

Radiation Treatment

Respiratory Disease

Rheumatic Fever

Sinus Problems

Stroke

Swollen Neck Glands

Ulcer

Venereal Disease
Are you under the care of a physician?
For what conditions?
Do you have any drug allergies or have ever had an adverse reaction to any medication or anesthesia?
Are you taking any medication at this time?
If so, what?
(Women) Do you suspect that you are pregnant?
Due Date
Are you nursing?
Is there anything else we should know about your medical history?

To the best of my knowledge, the information provided on this form is complete and correct. I understand that it is my responsibility to inform my doctor of any changes in my health.

Signature:
Date

CONSENT FORM FOR BLOOD TESTING

Our office policy states in the event of any employee poking him/her self with a used needle, concern to the patient and employee health a blood test must be done for any transmittal diseases. I give my consent to be escorted to the lab and have a blood test done at no charge to me.

Signature:
Date

Cancellation Charge Notice

Due to the time reserved for each patient, our office reserves the right to charge a $25 dollar fee for appointments cancelled less than 24 hours before the appointment or without notice. In the future if you have a change of phone number or address, please let us know immediately so we could update your file.

Signature:
Date

Privacy Practice Acknowledgement

I understand that Baseline Dental Care will not use or disclose health information about me unless I consent.

I also understand that I have the right to receive and review a written description of how this Practice will handle health information about me. This written description is known as a Notice of Privacy Practices and describes the uses and disclosures of health information made and the information practices followed by the employees, staff, and other office personnel of this practice, and my rights regarding my health information.

I understand that the Notice of Privacy Practices may be revised from time to time, and that I am entitled to receive a copy of any revised Notice of Privacy Practices. I also understand that I have the right to ask that some or all of my health information not be used or disclosed in the manner described in the Notice of Privacy Practices, and I understand that this practice is not required by law to agree to such requests.

Signature:
Date

THIS IS AN ONLINE FORM. DO NOT PRINT