Facebook
Instagram
Twitter
YouTube

{1}

##LOC[OK]##

2628 Genesee St., Utica, NY 13502
315.724.3768

Home
Office
Patient
Services
Smile Gallery
- Patient Testimonials
- Video Testimonials
Contact

Home
Office
Patient
Services
Smile Gallery
- Patient Testimonials
- Video Testimonials
Contact

Adult Form

_2017 Adult Registration Form – Dental

Patient Information

* Patient Name: (Required)

Gender: Male Female

Social Security Number:

Birth Date:

Age:

Home Address:

City:

State:

Zip:

Primary Phone Number:

Phone Type home cell

OK to leave message? Yes No

E-mail:

Employer's Name:

Occupation:

Spouse / Partner Information

Spouse/Partner's Name:

Marital Status: Single Married Divorced Widowed Significant Other

Social Security Number:

Birth Date:

Driver's License Number:

Address (if different than patient):

City:

State:

Zip:

Primary Phone:

Phone Type: home cell

Secondary Phone:

Phone Type: home cell

Emergency Contact Information

Emergency Contact's Name:

Phone Number:

Relation to Patient:

Address:

City:

State:

Zip:

Person(s) OK to release appointment or medically-related information to:

Relation to Patient:

Insurance Information

Primary Insurance

Primary Insurance Company:

Phone Number:

Group Number:

Policy Number:

Member ID Number:

Co-pay (if known):

Deductible (if known):

Policy Holder's Name:

Relation to Patient:

Policy Holder's SSN:

Policy Holder's Date of Birth:

Employer:

Work Phone Number:

Secondary Insurance

Secondary Insurance Company:

Phone Number:

Group Number:

Policy Number:

Member ID Number:

Co-pay (if known):

Deductible (if known):

Policy Holder's Name:

Relation to Patient:

Policy Holder's SSN:

Policy Holder's Date of Birth:

Employer:

Work Phone Number:

Dental History

How did you hear about our practice? Ad Internet Family/Friend Physician Other

Name of person referring(if applicable) :

Have your tonsils or adenoids been removed? Yes No

Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)? Yes No

Do you have any missing or extra permanent teeth? Yes No

Have you ever had an injury to (select all that apply): Teeth Mouth Chin

Do you have speech problems? Yes No

If so, explain:

Do your gums bleed? Yes No

Do you smoke? Yes No

Do you like your smile? Yes No

Do you currently or have you ever had any of the following habits(check all that apply): Clenching/Grinding Teeth Lip Sucking/Biting Mouth Breathing Nail Biting Thumb/Finger Sucking Chewing/Eating Problem

Medical History

Are you currently being treated by a physician? Yes No

Reason:

Physician:

Last Visit:

Phone:

Do you have any allergies/sensitivities to medications or latex? Yes No

If yes, please list:

Are you currently taking any prescription or over-the-counter medications? Yes No

If yes, please list with the dosage:

Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)? Yes No

Have you had any serious illnesses or operations? If yes, describe:

Have you ever had a blood transfusion? Yes No

If yes, give approximate dates:

(Women) Are you pregnant? Yes No

Nursing? Yes No

Taking birth control pills? Yes No

Check if you have ever had any of the following: Anemia Arthritis, Rheumatism Artificial Heart Valves Artificial Joints Asthma Back Problems Blood Disease Cancer Chemical Dependency Chemotherapy Circulatory Problems Cortisone Treatments Cough, Persistent Coughing Blood Diabetes Epilepsy Fainting Glaucoma Headaches Heart Murmur Heart Problems Hemophilia Hepatitis High Blood Pressure HIV/AIDS Jaw Pain Kidney Disease Liver Disease Mitral Valve Prolapse Pacemaker Radiation Treatment Respiratory Disease Rheumatic Fever Scarlet Fever Shortness of Breath Skin Rash Stroke Swelling of Feet or Ankles Thyroid Problems Tobacco Habit Tonsilitis Tuberculosis Ulcer Venereal Disease (STD)

Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status.

I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.

I understand that where appropriate, credit bureau reports may be obtained.

Submitted by:

Date:

Security Measure

google recaptcha

Manage your dental care online.

Appointments ➤
Financial & Insurance ➤
Patient Forms ➤
Pay Your Bill ➤

Belén Dental

Belén Dental - 2628 Genesee St., Utica, NY 13502 Phone: 315-724-3768 Email: [email protected]