This form is HIPAA compliant to ensure privacy.

Guyette Facial & Oral Surgery

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New Patient Registration Form

Patient Information

 

Date:
Sex:
Title: Date of Birth:
First Name:
  Age: (calculated after submit)
Middle Initial:
Social Security #:
Last Name:
  

 Email:
 
Street:
Home Tel. #:
City:
Business Tel. #:
State:
Ext.:
Zip:
Mobile Tel#:
Employer Name:
Occupation:
 
Dentist:
Dentist Phone #:
Referred By:
Medical Doctor:
Spouse Name:
Doctor Phone #:
    
 
Emergency Contact:
Home Tel. #:
 Relation:
Work Tel. #:
 
Marital Status:

Have you ever been a patient of our practice?
How were you referred to our office?



Person's Name:

Method of Personal Payment:
Are you a student?

 School:

Preferred appointment time:
 

Account Responsibility/Insurance Card Holder

 
Who will be responsible for your account? (if patient is a minor)
 
Title:

Date of Birth:

First Name:

Social Security #:
Middle Initial:
Driver's License #:
Last Name: Home Tel. #
  Email:

Street:

 Mobile Tel. #:

City:

Employer Name:

State:

Employer Tel. #:

Zip:

(if other) Relation:

Spouse or Guarantor Info (if different from above)

 
Title:

Social Security #:

First Name:

Tel. #:
Middle Initial:

Mobile Tel#:
Last Name:

Employer Name:
 

Street:

Employer Tel. #:

City:

Relation:

State:

 

Zip:

MEDICARE PATIENTS: DR. GUYETTE AND DR. BEEHNER ARE NOT MEDICARE PROVIDERS.
YOUR SERVICES RENDERED IN OUR OFFICE ARE NOT BILLABLE TO MEDICARE.
  

Primary Dental Insurance

 

Employer Name:

Group #:

Emp. Tel. #:

Subscriber Name:

Ins. Co. Name:

Subscriber Birthday:

Insurance Tel. #:

SSN/ID/Contract #:
Insurance PO Box:    
Relationship to Patient:

Primary Medical Insurance

 

Employer Name:

Group #:

Emp. Tel. #:

Subscriber Name:

Ins. Co. Name:

Subscriber Birthday:

Insurance Tel. #:

SSN/ID/Contract #:
Insurance PO Box:    
     Relationship to Patient:

Secondary Insurance

 

Type of Insurance:

Employer Name:

Group #:

Emp. Tel. #:

Subscriber Name:

Ins. Co. Name:

Subscriber Birthday:

Insurance Tel. #:

SSN/ID/Contract #:
Insurance PO Box:    
     Relationship to Patient: 

General Health

 

Are you in relatively good health?
Height:
Weight:
Have there been any changes in your general health in the past year?
If yes, please explain:
Date of last physical exam:
Have you ever had any serious illness, operations or been hospitalized?
If yes, please explain:
Do you have injuries or inflamed areas, growths or sore spots in or around your mouth?
Where:
Is this visit related to an accident?
When was the accident?
Do you smoke or chew tobacco?
If yes, how many packs per day:
Do you have any past history of Alcohol or Chemical Dependency?
Do you have a history of mental illness or emotional disorder?
Have you had any serious problems associated with any previous dental treatment?
Have you or an immediate family member had any problem associated with intravenous anesthesia?
Are there conditions or health issues that the doctor should be aware of?
Do you wish to speak to the doctor privately regarding your conditions?

Conditions - Do you have or have you ever had

 

High blood pressureRadiation (X-ray) treatment for Cancer
Low blood pressureHeart Murmur
Pain or clicking of jaw joint, pain near ear, difficulty in opening mouth, Grinding or clenching of teethMitral Value Prolapse
Damaged or diseased heart valvesAny disease, drug or transplant operation that has depressed your Immune system
Congenital Heart DiseaseSexually transmitted disease
Rheumatic feverHIV / AIDS
Cardiovascular Disease (Heart Attack, MI, Heart Trouble, Coronary Artery Disease, Chest Pain, Angina, Palpitations, Heart Surgery, Pacemaker, Irregular Heart Rhythm, Atrial Fibrillation)Delay in healing
Stroke (cerebrovascular accident; TIA - Transient Ischemic attack)Tumor or growth
Swollen anklesInfectious mononucleosis
Lung Disease (Emphysema, COPD, Chronic Cough, Bronchitis, Pneumonia, Tuberculosis, Shortness of Breath)Asthma (reactive airway disease)
Sinus, nasal problems, hayfeverSeizures, Convulsions, Epilepsy, Fainting/Dizziness
Bleeding Disorder, Anemia, Bleeding TendencyBlood transfusion
Bruises easilyLiver Disease, jaundice, Hepatitis
Kidney Disease, Kidney Stones, DialysisDiabetes
Low blood sugarThyroid Disease (Goiter, Hypothyroidism)
Arthritis (rheumatoid, ostesoarthritis)Stomach ulcers, GERD, Colitis
Eye Disease or GlaucomaOsteoporosis | osteopenia (bone density treatment)
Implants placed anywhere in your body (Heart Valve, Pacemaker, Hip, Knee)Other medical issues not listed on this page

Medication & Allergies

 

Are you using Antibiotics?
Are you using Anticoagulants (blood thinners)?
Are you using Aspirin or dugs such as Motrin, Aleve, Ibuprofen?
Are you using High Blood Pressure medications?
Are you using Steroids (Cortisone, Prednisone, etc.)?
Are you using Tranquilizers?
Are you using Insulin or Oral Anti-Diabetic drugs?
Are you using Digitalis, Inderal, Nitroglycerin or other heart drugs?
Are you taking or have you ever taken Bisphosphonate or other drugs for osteoporosis, multiple myeloma or other cancers (Reclast, Fosamax, Actonel, Boniva, Aredia, Zometa, Prolia, etc.)?
How long have you taken:
How long since taken:
Have you ever been advised not to take a medication?
Please list any and all medications taken, including prescription medication, diet drugs, over-the-counter medication, herbal or holistic remedies, vitamins or minerals:

Are you allergic to or have you had an adverse reaction to local anesthesia (Novacain, etc)?
Are you allergic to or have you had an adverse reaction to penicillin or other antibiotic?
Are you allergic to or have you had an adverse reaction to sedatives, barbiturates?
Are you allergic to or have you had an adverse reaction to aspirin or Ibuprofen?
Are you allergic to or have you had an adverse reaction to codeine or other pain killers?
Are you allergic to or have you had an adverse reaction to latex or rubber products?
Are you allergic to or have you had an adverse reaction to metal of any kind?
Are you allergic to or have you had an adverse reaction to chemicals or jewelry (rash or sensitivity)?
Are you allergic to or have you had an adverse reaction to food products?
Other allergies or reactions? Please list:

Women Only

 

Is it possible that you are currently pregnant?
Are you nursing?
Are you currently taking birth control medicine?

Family History (please  check  all  that  apply)

  

Acknowledgement
I hereby acknowledge that I have been given the right to review this office's Notice of Privacy Practices. (HIPAA) A copy of this notice can be viewed here.

I certify that I have read and understand the above.  I affirm that the information contained in this form and any additional information that I may furnish is true and correct to the best of my knowledge.  I understand the above information is necessary to provide me with dental care in a safe and efficient manner.  I will not hold Guyette Facial & Oral Surgery or the staff responsible for any errors or omissions that I have made in the completion of this form.

PLEASE TYPE YOUR NAME AND DATE BELOW BEFORE SUBMITTING
OR THIS FORM WILL NOT SUBMIT TO US
  
   Patient/Guardian Signature                                                                                       Date        
  
   Physician's Signature                                                                                               Date  
  
 
   
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