Clear Lakes Dental Registration Form Name First Middle Last DOB Date Format: MM slash DD slash YYYY Address Street Address City State / Province / Region ZIP / Postal Code SSN:Phone# Call Text Married Single Child Email How did you hear about us?Emergency Contact Information:Name First PhoneRelationshipFor Minors ONLY (17 years old and under): Parent/Legal Guardian’s Name:Phone Number:(Person responsible for account)Medical History: Do you have or have had any of the following? (Check all that apply) Acid Reflux Anemia Arthritis Artificial Joints Asthma Chemical Dependency Circulatory Problems Diabetes Epilepsy Heart Problems Hemophilia Hepatitis A B C High Blood Pressure HIV/AIDS Kidney Problems Low Blood Pressure Mental Health Disorders Migraines Pacemakers Psychiatric Care Radiation Treatment Rheumatic Disorders Sinus Problems Stomach Ulcers Stroke Thyroid Problems Tobacco User Tonsillitis Tuberculosis Venereal Disease Cancer: ____________ Other: _____________ NONE of the above Are you allergic to any of the following? (Check all that apply)Untitled Penicillin Tetracycline Aspirin Erythromycin Codeine Dental Anesthetics Latex NO Allerg Other Allergies:Medications you are currently taking:Primacy Physician Name / Clinic / Phone NumberAre you currently under the care of a physician? Yes / No Yes No WOMEN:Are you pregnant? Yes No If yes, how many weeks?Nursing? Yes No Taking birth controls? Yes No Check the box if you are a man. Yes Last Dental Clinic/VisitReason for Visit TodayAny problems associated with dental work? Yes / No If yes, please explainHow many times do you brush each day?How many times do you floss a weekCurrent Dental Health: [Excellent] [Good] [Fair] [Poor] (Please select one)Patient OR Parent/Legal Guardian’s Signature __________________________ Today’s Date __________ *Signatures will be collected in officeClear Lakes Dental Information Sharing Consent FormI give my permission to share information concerning:• My dental treatment • The costs and financial arrangements for my dental treatment • My personal health information • OtherI give my permission to share the above noted information with:My spouse (name & DOB)My parent(s) (name & DOB)My adult child or children (name & DOB)OtherSignature/ Date (Signatures will be collected in office) I do not wish to share any information with anyone Signature/ Date (Signatures will be collected in office) Δ
