Family Dental and Associates

FAMILY DENTAL ASSOCIATES

Lawrence: 978-725-0072 Reading: 781-944-0072 Haverhill: 978-521-3322

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Patient-Registration

Patient Registration & Health History

Patient Infomation

Free Text

New Field:

Last Name

First Name

Middle

Title

Address

City

State

Zipcode

Home Telephone

Business

Cell

Social Security Number

DOB

Email:

Dental Insurance Information:

Dental Insurance Information:

Free Text

Are you covered by Dental Insurance?

Yes/No

Yes

No

Subscriber's SS/ID

Subscriber's Name

Subscriber's Employer

Dental Insurance

Insurance

Telephone #

Group #

Subscriber's DOB

Seondary Insurance (if applicable)

Seondary Insurance (if applicable)

Subscriber's Name

Subscriber's SS/ID

Subscriber's Employer

Dental Insurance

Insurance Mailing Address

Telephone #

Group #

Subscriber's DOB

Have you had the following:

Have you had the following:

Yes/No

Yes

No

Checkboxes

Heart Problems

Heart Murmur

Angina

Diabetes

Cancer

Anemia

Arthritis

Asthma

HIV/AIDS

Checkboxes 2

Kidney Disease

Epilepsy

Nervous DIsorders

Stomach Disorders

Rheumatic Fever

Thyroid Disease

Hepatitis

Liver Disease

Checkboxes 3

Mitralvalve Prolapse

Sexually Transmitted Disease

Irregular Heart Beat

High Blood Pressure

Scarlet Fever

Lung Disease

Tuberculosis

Joint Replacement

Women Only:

WOMEN ONLY:

Are you pregnant

Are you pregnant?

Yes/No

Option 1

Option 2

Free Text

How long?

New Field:

Medical History

MEDICAL HISTORY

Physician's Name

Phone #

Have you ever treated with radiation?

Enter your free text here

Yes/No

Yes

No

Are You being treated with anything now?

Are you allergic to?

Are you allergic to?

Checkboxes

Penicillin

Codeine

Novocaine

New Field:

Do you take any prescription or over the counter drugs (including aspirin) on a regular basis?

Do you take any prescription or over the counter drugs (including aspirin) on a regular basis?

Yes/No

Yes

No

If yes, Please list:

DENTAL HISTORY

How long since last dental exam?

Dental concerns:

Emergancy Contact:

Telephone #

Referred By:

Signature

Signature:

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Home Page
Our Team
Our Services
Our Locations

Reading Square: 636 Main Street
Reading, MA 01867
Fax: 781-944-0454

Lawrence: 160 Winthrop Avenue
South Lawrence, MA 01843
Stadium Plaza Rte. 114 at 495
Fax: 978-725-6699

Haverhill: 108 Merrimack St.,
Haverhill, MA 01830
Fax: 978-521-3988

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