Patient verification

Patient Information
Last, First MI (Preferred Name)
Birth Date: Phone (Home): ____
For your convenience, please provide your E-mail Address:_____________________ for appointment reminders.
Reason for this visit: ___________________________ Are you in good health? (Y) (N) If no, please explain:__________________________________________
Has there been any change in you general health this past year? ( Y ) ( N )
Have you ever or do you have any of the following? Please check all those that apply:

ALLERGIES:
Other Allergies:
____________________________________________________________________________________________________________
MEDICATIONS: Are you taking any of the following? Please list:
( ) Antibiotics? _______________
( ) Insulin or anti-diabetic drugs? _______________ ( ) Anticoagulants (blood thinners)? ______________ ( ) Aspirin or drugs such as Motrin, Aleve, Ibuprofen? _____ or other heart drug? _________________________ ( ) High blood pressure medications? ________________ ( ) Tranquilizers?____________________________ ( ) Steroids (Cortisone, ect.)?__________________
Other Medications:___________________________________________________________________________

Have you ever been advised to pre-medicate before dental procedures? (Y) (N)
Are you or have you ever taken Bisphosphonates: (FOSAMAX, ACTONEL OR BONIVA for osteoporosis, Aredia or Zometa for
various cancers, ect.)? (Y) (N)
 Have you ever had any complications following dental treatment? Yes
No If yes, please explain:
 Have you been admitted to a hospital or needed emergency care during the past two years? Yes
No If yes, please explain:
 Are you now under the care of a physician? Yes
No If yes, please explain:
 Name of Physician: _______________________________________________ Phone:
For Women Only:
Are you pregnant, or is there any chance you might be? (Y) (N) Are you nursing? (Y) (N)
If you are using Oral Contraceptives, it is important that you understand that antibiotics (and some other medications) may interfere with the effectiveness of oral
contraceptives. Therefore you will need to use mechanical forms of birth control for one complete cycle of birth control pills, after the course of antibiotics or other
medication is completed. Please consult with your physician for further guidance.
Doctor notes:__________________________________________________________________________________________________

To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my
health, I will inform the doctors at the next appointment without fail.
_________________________________________________________________ Date:
Signature of patient, parent or guardian
Patient Information
Last, First MI (Preferred Name) Gender: Male
In the event of an emergency, whom should we contact? Please list someone NOT living with you.
Name___________________________________ Phone:__________________ Relationship to you__________

Responsible Party
Name:__________________________________________________________________________ The following is for: the patient the person responsible for payment Employer Name Insurance Information

Name of Insured: ________________________________ Is the insured a patient?
Insured's Birth Date: _________________ ID# or SS#: _____________________ Group #:_________ Insured's Address:___________________________________________________________________________________ Insured's Employer Name and Address:__________________________________________________________________ ___________________________________________________________________ Patient's relationship to insured: Insurance Plan Name and Address: ___________________________________________
How did you find out about Lighthouse Dental?

Location of our office Yellow Pages Insurance Carrier Friend/Relative Other :
Whom may we thank for referring you to our practice:_____________________________________

Source: http://www.lighthousedental.biz/forms/Patient%20Registration%20Form.pdf