Patient Registration

Endodontic Associates

Dr. Robert Chavez, DDS, MS, PC

 

          PLEASE PRINT

Patient Information and Health History

 

Patient Name:______________________________________Todays’ Date________

 

Relationship to Patient (if minor): _Mother_Father Name:________________________

 

Address___________________________City, State, Zip ________________________

 

Phone (___) _________  Work (___) __________  Cell (___) _____________________

 

Date of Birth ___________________        Social Security #_______________________

 

Employer:______________________________________________________________

 

Employer Address_______________________________________________________

 

Emergency Contact _______________________________Phone_________________

 

Referring Dentist:________________________________________________________

 

Insurance Information

 

Insurance Co:________________________________Phone # ____________________

 

Subscriber Name___________________________Employer______________________

 

Insured’s Social Security #_________________________Date of Birth:_____________

 

 

DENTAL INSURANCE CLAIMS WILL BE FILED AS A COURTESY TO OUR PATIENTS. WE WILL CONFIRM BENEFITS PRIOR TO TREATMENT, AND THE PATIENT PORTION IS DUE AND PAYABLE AT THE TIME OF TREATMENT

                                                                                                Initial here________

 

I _________________________________________consent to and exam and xrays to diagnose my chief complaint

Signature________________________________________Date________Time:_____

 

Witness_________________________________________Date_______  Time:______

 

 

 

HEALTH HISTORY

Endododontic Associates, LLC

Robert D. Chavez, DDS, MS, PC

 

Patient:___________________________________Age_______Todays’ Date________

 

Are you currently under the care of a physician?  Y /N

 If Yes for what______________________________________

Physician’s name_______________________________________________________________

Do you have or have you ever had any of the following:

_ Heart Disease                       _ Radiation/Chemotherapy

_ Heart Attack                          _ Psychiatric care

_ High Blood Pressure            _ Fainting tendency

_ Heart Murmur                      _ HIV/AIDS

_ Rheumatic Fever                 _ Hip/Joint Replacement

_ Mitral Valve Prolapse           _ Lung Problems/Asthma

_ Shortness of Breath              _ Sinus Problems

_ Chest Pains                          _ Glaucoma

_ Liver Problems                      _ Diabetes

_ Hepatitis                               _ Anemia

_ Thyroid Disease                   _ Bleeding Problems

_ Tuberculosis                         _ Systemic Lupus

_ Severe headaches                _ Latex/Rubber Allergy

_ Seizures                                _ Treatment with steroids

_ Stomach Ulcers                   _ Organ Transplant

_ Kidney Problems                 _ Currently pregnant

_ Cancer                                             

Do you have a history of drug abuse? Y/N                           

Do you have any other medical problems not listed above? Y/N

If, yes what?___________________________________________________________

 

Have you taking or have you ever taken any bone replacement therapy for osteoporosis or bone cancer?  Y/N  If yes, what?__________________________________________

 

Are you allergic to any medications?  Y/N If yes list them_________________________

______________________________________________________________________

Are you allergic to Latex? Y/N

 

Please list all medications you are taking at this time:

________________________________________________________________________ ____________________________________________________________________

 

The above information is true to the best of my knowledge. I have also had the opportunity to review the Notice of Privacy Practices.

Signature_________________________________________________Date_________