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Microsoft word - new-patient-registration-form

BestCare Family Dental
88-09 Northern Boulevard
Jackson Heights, N.Y. 11372
(718) 429-7744
Name _________________________________ Address __________________________________________________________________________________ Emergency Contact: Name ___________________ Dental Insurance: Phone _____________________ If you are completing this form for another person, what is your relationship to that person? ___________________ Referred by ___________________________________________ HAVE YOU HAD:
Are you in good general health?
Are you now taking any drugs or medications? (Novocaine or Xylocaine) by a dentist or doctor? Have you ever had any adverse reaction to either Do you take aspirin products or anti-inflammatory Other:_________________________________________ PLEASE LIST ALL PREVIOUS SURGERIES AND DATES:
Have dentures, false teeth, caps or bridges __________________________________________________ _________________________________________________ Have any contagious or infectious condition Dental Questionnaire:

NO YES Are you happy with your smile?
NO YES Are you interested in straighter teeth (Invisalign)?
NO YES Would you like to change the whiteness of your teeth and/or fillings?
NO YES Are you interested in replacing missing teeth?
NO YES Do your gums bleed?
NO YES Do you have bad breath/unpleasant taste?
NO YES Do you have swelling/lumps in your mouth?
NO YES Are your teeth sensitive to cold/hot/sweets/pressure?
NO YES Do you clench/grind your teeth?
NO YES Have you had an unfavorable dental experience? Please explain: __________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Chief Dental Complaints ______________________________________________________________________________________
____________________________________________________________________________________________________________

The above information is strictly confidential
I certify that I have read and understood the above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form.
For completion by the dentist.
Comments on patient interview concerning medical history:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Significant findings from questionnaire or oral interview: ____________________________________________________________
______________________________________________________________________________________________________________

______________________________________________
Signature of Dentist
Medical History Update:
Date

Comments
Signature
_______________ ____________________________
___________________
_______________ ____________________________
___________________
_______________ ____________________________
___________________

Source: http://www.bestcarefd.com/docs/New-Patient-Registration-Form.pdf

Ash v2 i4

American Society of Hypertension Current Concepts in Hypertension Editor’s Comments The Losartan Intervention For Endpoint Reduction Wading Through the Alphabet Soup (LIFE) in Hypertension Study As the century draws to a close, a plethora of outcome stud-ies are in progress to compare the effects of specific The Losartan Intervention For Endpoint Reduction (LIFE) in

D:\lichtkegel\ges. angew. philo\literaturliste.wpd

Literatur zur philosophischen Praxis ACHENBACH Gerd: Philosophische Praxis, Köln 19872 BADURA Jens: Die Suche nach Angemessenheit. Praktische Philosophie als ethische Beratung,BAUSCH Thomas / KLEINFELD Annette / STEINMANN Horst (Hg.): Unternehmensethik in derBERG Melanie: Philosophische Praxen im deutschsprachigen Raum. Eine kritische Bestands-BIRNBACHER Dieter / KROHN Dieter (Hg.): Das so

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