New Patient Registration Form

Patient Information

Title:
Sex:
First Name:

Date of Birth:

Last Name:
  
Age:
(calculated after submit)
 

 Personal Health #:
   

 Email:
 
Street Address:
Home Tel. #:
City:
Work Tel. #:
Province:
Ext.:
Postal Code:
Cell #:
Employer Name:
 
 
Dentist:
Emergency Contact:
Physician:
 
 
 

Account Responsibility/Insurance Card Holder
Who will be responsible for your account? (if patient is a minor)
 
Title:

Date of Birth:

First Name:

SIN:

Middle Initial:
Home Tel. #
Last Name:

 Cell #:
 

Street Address:

 Email:

City:

    

Province:

Postal Code:

   

Spouse or Guarantor Info (if different from above)
Title:

SIN:

First Name:

Tel. #:
Middle Initial:

Mobile Tel#:
Last Name:

Employer Name:
 

Street Address:

Emp. Tel. #:

City:

Relation:

Province:

 

Postal Code:


Primary Dental Insurance

   

Group #:

Ins. Co. Name:

Subscriber Name:
   

Subscriber Birthday:
   

ID/Contract #:
   

Dependent Number:
       
   

Secondary Dental Insurance
   

Group #:

Ins. Co. Name:

Subscriber Name:
   

Subscriber Birthday:
   

ID/Contract #:

   

Dependent Number:
       
   

General Health
Are you in relatively good health?
Weight:
Have there been any changes in your general health in the past year?
If yes, please explain:
Are you under the care of a physician?
Date of last visit:
For what are you being treated?
Have you had any illness, operation or been hospitalized in the past five years?
If yes, please explain:
Is this visit related to an accident?
When was the accident?
Please List:
Do you wish to speak to the doctor privately regarding your conditions?

Conditions
High / Low blood pressureChest pain / angina
Heart MurmurIrregular heartbeat
Cardiac pacemakerHeart surgery
StrokeHeart attack(s)
Swollen ankles, arthritis, or joint diseaseRheumatic fever
Problems with the immune systemSexually transmitted diseases
Tumor or growthX-Ray treatment / chemotherapy
Delay in healingMalignant hyperthermia
Immunodeficiency disease I smoke
Difficult breathing / other lung troubleBronchitis / chronic cough
Asthma / EmphysemaHay fever / sinus problems
Thyroid troubleDiabetes
Stomach ulcersGallbladder trouble
Blood disorderBruise easily
Bleeding tendency (abnormal bleeding)Mental health problems
History of drug / alcohol abuseConvulsions / epilepsy
Fainting spellsKidney trouble / Dialysis
Eye Disease / GlaucomaContact lenses
HepatitisOther Medical Issues not listed above

Medication & Allergies
Are you taking any kind of medicine, drugs, or pills?
Please list:

Please list all allergies and adverse reactions that you are aware of below:

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

Fees and Payments
We make every effort to keep down the cost of your oral surgical care.  You can help by paying upon completion of each visit.  Other arrangements can be made with our office manager depending upon special circumstances. An estimate of the charge for any procedure or surgery you may require will be given to you upon request. If you have any dental insurance we will be glad to fill out the proper forms, but please complete the identifying information on this form.  

Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid for by your insurance company. You will be responsible for all collection costs, attorneys fees, and court costs.

I certify that I have read and understand the above. 
I authorize the release of information necessary to process my claim. I hereby authorize to this doctor named of the benefits otherwise payable to me. 
Patient Acknowledgements
I hereby acknowledge that I have been given the right to review the Notice of Privacy Practices for this office. (PIPA) 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 Dr. Andreas A. Conradi, Inc.  or the staff responsible for any errors or omissions that I have made in the completion of this form.

  
  Signature                                                                                                                 Date        

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