Medical Form | Affordable Cosmetic Dentist in Eureka, CA

PATIENT REGISTRATION

"*" indicates required fields

Step 1 of 10

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Asterisk(*) = Mandatory field

Please choose location*

Please choose appointment*

If this appointment is for you start here:

Date

MM slash DD slash YYYY

Name

First Middle Last

Prefers to be called by

Adress

City

State

Zip

Home Phone No.

Fax

Cell

Date

MM slash DD slash YYYY

Age

Gender

Male

Female

marital status

Married

Single

Divorced

Widowed

Social security No.

If this appointment is for your child start here:

Date

MM slash DD slash YYYY

Name

First Middle Last

Adress

City

State

Zip

Home Phone No.

Date

MM slash DD slash YYYY

Age

Gender

Male

Female

School

Grade

Social security no.

Dental Insurance

Primary Carrier

Insurance Company

Group No.

Employer Name

Insured's Name

Date of Birth

MM slash DD slash YYYY

Relationship to Patient

Insured's Social Security No.

Dental Insurance

Secondary Carrier

Insurance Company

Group No.

Employer Name

Insured's Name

Date of Birth

MM slash DD slash YYYY

insured's ID No.

Insured's ID No.

Insured's Social Security No.

Getting to Know You

Is another member of your family or relative a patient at our office?

Name

Relationship

You were referred to us by

Name

Person to contact for emergency

Name

Cell Number

Home Number

Address

City

State

ZIP

Person financially responsible for account

Name

Relationship to Patient

Social Security No.

Address

City

State

ZIP

Phone No.

You

Name

Occupation

Employer's Name

Address

City

Phone No.

Fax No.

Your Spouse

Name

Occupation

Employer's Name

Address

City

Phone No.

Fax No.

CONSENT FOR TREATMENT

I hereby authorize doctor or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of (name of patient)'s dental needs.
Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.
I agree to the use of anesthetics, sedatives and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.
I give consent to the doctor's or designated staff's use and disclosure of any oral, written or electronic health records that are individually identifiable as mine for the purpose of carrying out my treatment, payment and health care operations. I understand that only the minimum amount of information necessary to provide quality care will be used or disclosed and that a notice fully outlining the protection of my personal health information is available.
I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that payment is due at the time of service unless other arrangements have been made. In the event payments are not received by agreed upon dates, I understand that a 1-1/2% late charge (18% APR) may be added to my account. If required, I also understand a check of my credit history may be made.

Date

MM slash DD slash YYYY

Witness

Relationship to Patient

Signature

MEDICAL HISTORY

Asterisk(*) = Mandatory field

Physician’s Name

Phone

Have you had any medical care within the past two years?*

Yes

Describe*

Have you taken any medication or drugs during the past two years?*

Yes

If yes, please list name and dosage*

Are you currently taking any medication, drugs, pills or herbal remedies, including regular dosages of aspirin?*

Yes

If yes, please list name and dosage*

Have you ever taken bone loss prevention drugs such as Fosamax, Actonel, Boniva or other bisphosphonates?*

Yes

If yes, please list name and dosage

Are you aware of having an allergic (or adverse) reaction to any substance or medication?*

Yes

If yes, please specify*

Have you been a patient in the hospital during the past five years?*

Yes

Indicate which of the following you have had, or have at present.

Heart (Surgery, Disease, Attack)*

Yes

Ulcers*

Yes

Hepatitis A B C (circle)*

Yes

Chest Pain*

Yes

Diabetes*

Yes

Venereal Disease*

Yes

Congenital Heart Disease*

Yes

Thyroid Problems*

Yes

A.I.D.S./H.I.V. Positive*

Yes

Heart Murmur*

Yes

Glaucoma*

Yes

Cold Sores/Fever Blisters*

Yes

High/Low Blood Pressure*

Yes

Contact lenses*

Yes

Blood Transfusion*

Yes

Mitral Valve Prolapse*

Yes

Emphysema*

Yes

Hemophilia*

Yes

Artificial Heart Valve/Pacemaker*

Yes

Chronic Cough*

Yes

Sickle Cell Disease*

Yes

Rheumatic Fever*

Yes

Tuberculosis*

Yes

Bruise Easily*

Yes

Arthritis/Rheumatism*

Yes

Asthma*

Yes

Liver Disease/Yellow Jaundice*

Yes

Cortisone Medicine*

Yes

Hay Fever/Allergy/Hives*

Yes

Neurological Disorders*

Yes

Swollen Ankles*

Yes

Latex Sensitivity*

Yes

Epilepsy or Seizures*

Yes

Stroke*

Yes

Sinus Trouble*

Yes

Fainting or Dizzy Spells*

Yes

Diet (Special/Restricted)*

Yes

Radiation Therapy*

Yes

Nervous/Anxious*

Yes

Artificial Joints (hip, knee, etc.)*

Yes

Chemotherapy*

Yes

Psychiatric/Psychological Care*

Yes

Kidney Trouble*

Yes

Tumors*

Yes

Cancer*

Yes

Have you lost or gained more than 10 pounds in the past year?*

Yes

Do you have or have you had any disease, condition, or problem not listed?*

Yes

If yes, please list:*

Are you pregnant or think you could be pregnant?*

Yes

Do you use birth control prescriptions?*

Yes

Consent

I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of any change in my health or medication.

DENTAL HISTORY

Welcome! So that we may provide you with the best possible care please complete both sides of this medical/dental history form. All information is completely confidential.

What is the reason for your visit today?

Date of Last Dental Visit

MM slash DD slash YYYY

Last Dental Cleaning

MM slash DD slash YYYY

Last Full Mouth X-rays

MM slash DD slash YYYY

What was done at your last dental visit?

Previous Dentist’s Name

Telephone

Address

State

ZIP

How often do you have dental examinations?

How often do you brush your teeth?

How often do you floss?

Have you ever used or are currently using topical fluoride?*

Yes

What other dental aids do you use? (Interplak, toothpick, etc.)

Do you have any dental problems now?*

Yes

If yes, please describe*

Are any of your teeth sensitive to

Hot or cold?*

Yes

Sweets?*

Yes

Biting or Chewing?*

Yes

Have you noticed any mouth odors or bad tastes?*

Yes

Do you frequently get cold sores, blisters or any other oral lesions?*

Yes

Do your gums bleed or hurt?*

Yes

Have your parents experienced gum disease or tooth loss?*

Yes

Have you noticed any loose teeth or change in your bite?*

Yes

Does food tend to become caught in between your teeth?*

Yes

If yes, where*

Yes

If yes, where*

Have you ever had:

Orthodontic treatment?*

Yes

Oral Surgery?*

Yes

Periodontal treatment?*

Yes

Your teeth ground or the bite adjusted?*

Yes

A bite plate or mouth guard?*

Yes

A serious injury to the mouth or head?*

Yes

Please describe, including cause*

Do you:

Clench or grind your teeth while awake or asleep?*

Yes

Bite your lips or cheeks regularly?*

Yes

Hold foreign objects with your teeth? (pencils, pipe, etc.)*

Yes

Mouth breathe while awake or asleep?*

Yes

Have tired jaws, especially in the morning?*

Yes

Snore or have any other sleeping disorders?*

Yes

Smoke/chew tobacco or use other tobacco products?*

Yes

Have you experienced:

Clicking or popping of the jaw?*

Yes

Pain? (joint, ear, side of face)*

Yes

Difficulty in opening or closing the mouth?*

Yes

Difficulty in chewing on either side of the mouth?*

Yes

Headaches, neckaches or shoulder aches?*

Yes

Sore muscles (neck, shoulders)?*

Yes

Have you experienced:

Would you like to replace your silver fillings?*

Yes

Would you like to keep all of your teeth all of your life?*

Yes

Do you feel nervous about having dental treatment?*

Yes

If yes, Please describe*

Have you ever had an upsetting dental experience?*

Yes

If yes, Please describe*

Have you ever been told to take a pre-medication prior to dental treatment?*

Yes

Is there anything else about having dental treatment that you would like us to know?*

Yes

PATIENT REGISTRATION

Dental Insurance

Dental Insurance

Getting to Know You

MEDICAL HISTORY

DENTAL HISTORY

Our Office

831 Harris St. Eureka, CA 95503

Phone: (707) 375-9698

Fax: (707) 443-1467

Email: info@drmehtadentist.com

Hours

Monday: 8 AM - 5 PM

Tuesday: 8 AM - 5 PM

Wednesday: 8 AM - 5 PM

Thursday: 8 AM - 5 PM

Friday: 8 AM - 5 PM

Saturday: 8 AM - 5 PM

Sunday: Closed

© 2024 Ajay Mehta DDS

Terms & Conditions

Privacy Policy

PATIENT REGISTRATION

Dental Insurance

Dental Insurance

Getting to Know You

CONSENT FOR TREATMENT

MEDICAL HISTORY

DENTAL HISTORY

Our Office

831 Harris St. Eureka, CA 95503

Phone: (707) 375-9698

Fax: (707) 443-1467

Email: info@drmehtadentist.com

Hours

Monday: 8 AM - 5 PM

Tuesday: 8 AM - 5 PM

Wednesday: 8 AM - 5 PM

Thursday: 8 AM - 5 PM

Friday: 8 AM - 5 PM

Saturday: 8 AM - 5 PM

Sunday: Closed

© 2024 Ajay Mehta DDS

Terms & Conditions

Privacy Policy

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