Patient Registration
The following registration information will be collected prior to your first treatment visit in our office.
Patient Registration Form
Date:_______________
Name: _______________________________________________________
Address: ______________________________________________________
City:___________________State:____________________ Zip: _________
Home Phone: _________________________________________________
Cell Phone: __________________________________________________
Email Address: ___________________________________________________
Date of Birth:____________ Gender:_________ Ht._____ Wt. _________
Marital Status: ________________________________________________
Dental Insurance Company: ______________________________________
Name of Insured: ______________________________________________
Employer (of insured): __________________________________________
Social Security Number (of insured): _______________________________
Referred by: __________________________________________________
General Dentist: _____________________________ Phone: ___________
Primary Care Physician: _______________________ Phone: ___________
Most Recent Physical Exam: _____________________________________
Closest Relative: _____________________________ Phone: ___________
Emergency Contact: ___________________________ Phone: ___________
Medical History Information
(it is in your best health interest to be accurate and honest)
Physician’s name (medical doctor): _____________________________________
Physician’s phone: __________________________________________________
Most Recent Physical Exam Date: ______________________________________
Have you ever had or do you presently have:
Heart attack Yes or No
if yes, Date:_________________________________
Heart Surgery Yes or No
if yes, Date:_________________________________
Prosthetic Heart Valve Yes or No
if yes, Date:_________________________________
Previous Infective Endocarditis Yes or No
if yes, Date:_________________________________
Congenital Heart Disease Yes or No
if yes, Date:_________________________________
Heart Murmur Yes or No
if yes, Date:_________________________________
Mital Valve Prolapse Yes or No
if yes, Date:_________________________________
Chest Pain Yes or No
if yes, how often, and last episode:_______________
High Blood Pressure Yes or No
if yes, most recent reading:_____________________
Low Blood Pressure Yes or No
if yes, most recent reading:_____________________
Stroke Yes or No
if yes, Date:_________________________________
Artificial Joints (Hip, Knee) Yes or No
if yes, Type & Date:___________________________
AIDS or HIV positive Yes or No
Hepatitis A (infectious) Yes or No
Hepatitis B (serum) Yes or No
Hepatitis C Yes or No
Yellow Jaundice Yes or No
Kidney Disease Yes or No
Drug Addiction Yes or No
if, yes, Type:________________________________
Blood Transfusion Yes or No
if yes, Date:_________________________________
Bleeding Problems Yes or No
if yes, Type:_________________________________
Bruise Easily Yes or No
Anemia Yes or No
Tuberculosis Yes or No
if yes, Date:_________________________________
Fever Blisters Yes or No
Epilepsy or Seizures Yes or No
Fainting or Dizzy Spells Yes or No
Nervous Disorders Yes or No
if yes, Type:________________________________
Glaucoma Yes or No
Cancer Yes or No
if yes, what type: ____________________________
Leukemia Yes or No
if yes, what type:_____________________________
Chemotherapy Yes or No
if yes, Date:_________________________________
Cobalt/Radiation Treatments Yes or No
if yes, Date:_________________________________
Emphysema Yes or No
Asthma Yes or No
if yes, is Inhaler required for dental treatment?______
Hay Fever Yes or No
Sinus Problems Yes or No
Allergies or Hives Yes or No
Diabetes Yes or No
if yes, type:_________________________________
insulin requirement:_____________________
oral medication required:_________________
diet and exercise only: Yes or No
Thyroid /Disease (Overactive/Underactive) Yes or No
if yes, medication taken:_______________________
Ulcers Yes or No
Cortisone Medication Yes or No
if yes, Oral medication:_________________________
if yes, Injection only, Date: ______________________
if yes, Topical medication only:___________________
Have you taken or are you taking bone density medication?
Yes or No
if yes, circle or list the type of bone density drug:
Actonel, Fosamax, Aredia, Zometa, other________
if yes, when, how long, was the bone density drug taken:
______________________________________________
Have you taken bisphosphonate medications for any other purpose?
Yes or No
if yes, list drug, when and how long taken:_______________
Are you pregnant? Yes or No
Are you taking birth control medications? Yes or No
Are you breast feeding? Yes or No
Are you allergic or have you reacted adversely to any of the following?
Aspirin Yes or No
Tylenol Yes or No
Codeine Yes or No
Ibuprofen Yes or No
Latex (Rubber) Yes or No
Hydrocodone/Vicodin Yes or No
Amoxicillin Yes or No
Penicillin Yes or No
Erythromycin Yes or No
Clindamycin Yes or No
Local Anesthetic Yes or No
Valium Yes or No
Sulfa Drugs Yes or No
Are you aware of being allergic to any other medication or substances? If yes please list:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Are you taking any medication? Yes or No
If yes, please list the medications: ______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Are you taking any vitamins or herbal supplements? Yes or No
If yes, please list any vitamins or nutritional supplements you may be taking:
_______________________________________________________________________
________________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
________________________________________________________________________
Please list any other medical or dental information that you feel the doctor should be told:
_________________________________________________________________________
_________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_________________________________________________________________________
I certify that these statements concerning my health are correct to the best of my knowledge:
_________________________________________________________________________
Print name
__________________________________________________________________________
Signature
Date: ________________
Privacy Policy
I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPPA), I have certain rights to privacy regarding my protected health information.
I understand that the information collected by this office can and will be used to: conduct, plan, and direct, my treatment and follow-up care among the multiple health care providers who may be involved in that treatment directly and indirectly. Obtain payment from third-party payers (i.e. employers and insurance programs). Conduct normal health care operations such as quality assessments and physician certifications.
I acknowledge that I may request your “Notice of Privacy Practices” document which contains a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change the “Notice of Privacy Practices” informational form from time to time, and that I may contact this organization at any time to obtain a current copy of the “Notice of Privacy Practice”.
Date:__________________
Signed:________________________________________________________________
Print Name:_____________________________________________________________
Communication Policy
Communication is a very important part of providing quality health care. In an effort to provide you with timely information regarding your healthy care, we ask that you complete the following:
We normally contact our patients between 8:00am and 5:00pm. You will be asked to provide the phone number that we should use to contact you during that time period:
( )____________________________ Home Work Cell Other
If you are unavailable at the time we contact you, may we leave medical information with another person? Yes No
Can we leave a message on an answering machine or with another person while confirming the appointment? Yes No
Date:__________________
Signed:________________________________________________________________
Print Name:_____________________________________________________________
Patient Consent & Expectations for Endodontic Treatment at FVES
- I will authorize Dr. Rauschenberger, Dr. Shariff, and any other agents or employees of Fox Valley Endodontic Specialists and such assistants as may be selected by any of them to treat the conditions described to me at my initial treatment or consultation appointment in their office.
- The Procedure(s) necessary to treat the conditions(s) will be explained to me for one or more of the following procedures: a Root Canal Treatment, an Emergency Treatment Procedure to address pain and/or swelling, a Root Canal Re-treatment Procedure, a Root Canal Surgical Procedure, or a Diagnostic Pain or other Diagnostic Endodontic Evaluation.
- I will be informed of the possible alternative methods of treatment including no treatment at all.
- The doctor will explain to me the inherent and potential risks in any treatment plan or procedure.
- It will be explained to me that a perfect result is not guaranteed or warranted and cannot be guaranteed or warranted when providing treatment options by humans for the human body. The expectation or prognosis for a successful treatment will be provided to me according to available scientific evidence and my clinical condition prior to the initiation of the procedure.
- I will be given the opportunity to question the doctor concerning the nature of the treatment, the inherent risks of the treatment, and the alternatives to the treatment.
Date:__________________
Signed:_______________________________________________________
Name printed:__________________________________________________