patient registration form today’s date s m p d...

Patient Registration Form

500 Davis St., Suite 510 Evanston, Illinois 60201 847.864.2243 www.evanstondentalassociates.com

Today’s Date _________________________

Name ___________________________________________________________________________

Address__________________________________________________________________________

City ___________________________________________State ___________Zip________________

Home Phone _______________________ Work ___________________ Cell __________________

Birthdate ____ /____ / ____ Male Female Marital Status S M P D W

Email ____________________________________________________________________________

Best method to contact you______________________________________

Social Security Number _________ - _______ - __________

How were you referred to our office?____________________________________________________

Do you use the following? □ Facebook □ Yelp □ Twitter □ Google+ □ None Of Them

What is your favorite movie? __________________________________________________________

What kind of music do you like? _______________________________________________________

Responsible Party’s Name (if different from above) ________________________________________

Relationship to Patient ______________________________________________________________

Address __________________________________________________________________________

City ___________________________________________State ___________Zip________________

Home Phone _______________________ Work ___________________ Cell __________________

Social Security Number _________ - _______ - __________

Person to contact in an emergency:

Name__________________________________________ Phone Number _____________________

Insurance Information Form


Today’s Date____________

Sponsor of Plan Name ____________________________________________________

Sponsor Address ____________________________________________________

____________________________________________________

Primary Dental Insurance Company ___________________________________________________

Mailing Address for Dental Claims ____________________________________________________

____________________________________________________

Member/Subscriber Name ________________________________ Date of Birth _____/_____/_____

Relationship to subscriber self spouse dependent

Group Number _______________________Subscriber ID Number ___________________________

Secondary Dental Insurance Company _________________________________________________

Mailing Address for Dental Claims ____________________________________________________

____________________________________________________

Member/Subscriber Name ________________________________ Date of Birth _____/_____/_____

Relationship to subscriber self spouse dependent

Group Number _______________________Subscriber ID Number ___________________________

Full payment is expected at the time of service, unless prior arrangements have been made. As a

courtesy, we are happy to submit insurance forms on your behalf. In order to do this, we must have

your correct insurance information on file. Please read your policy carefully. We strive to provide the

most appropriate quality treatment for our patients. Some or all of the service we provide may not be

a covered benefit. Please be aware of your insurance plan’s limitations, exclusions and plan

maximums. The entire account balance remains your responsibility.

Dental History Form


Welcome! So that we may provide you with the best possible care, please complete the entire dental history

form. All information will be kept completely confidential.

Today’s Date______________

Purpose of your visit today ________________________________________________________________

_____________________________________________________________________________________

Previous Dentist’s Name__________________________________________________________________

Address ________________________________ City ___________________ State ______ Zip _________

Phone_________________________________________________________________________________

Date of Last Dental Visit __________ Last Dental Cleaning __________ Last Full Mouth X-rays _________

How often do you brush your teeth? ___________________ How often do you floss? __________________

Are any of your teeth sensitive to: (check all that apply) Hot Cold Sweets Biting Chewing

If yes, where? __________________________________________________________________________

Have you noticed any mouth odors or bad tastes? Yes No

Do you ever get cold sores, blisters or any other mouth/lip lesions? Yes No

Have you noticed any loose teeth or a change in your bite? Yes No

Does food tend to get caught in between your teeth? Yes No

Do you:

Clench or grind your teeth? Yes No

Have tired jaws (esp. in the morning)? Yes No

Frequently bite your lips or cheeks? Yes No

Smoke/chew tobacco? Yes No

Breathe through your mouth? Yes No

Hold foreign objects in your teeth? Yes No

Have you experienced:

Clicking/popping of the jaw? Yes No

Difficulty chewing? Yes No

Difficulty opening/closing your mouth? Yes No

Headaches, neck pain or shoulder pain? Yes No

Have you ever had:

Orthodontic treatment? Yes No

Periodontal (Gum) treatment? Yes No

A bite plate or mouth guard? Yes No

Oral Surgery? Yes No

Your teeth ground or your bite adjusted? Yes No

A serious injury to your mouth or head? Yes No

If yes, please describe ___________________________________________________________________

Are you satisfied with the appearance of your teeth? Yes No If no, please describe ____________

______________________________________________________________________________________

Do you feel nervous about having dental treatment? Yes No If yes, what is your biggest concern?

______________________________________________________________________________________

Is there anything else about having dental treatment that you would like us to know? ___________________

______________________________________________________________________________________

Medical History Form


Have you been under the care of a medical doctor during the past two years? Yes No

If yes, for what? _________________________________________________________________________

Physician’s Name _______________________________________________________________________

Are you taking any medications now? Yes No If yes, please list name and dosage:

______________________________________________________________________________________

Are you allergic or have adverse reaction to any medications? Yes No If yes, please list them:

______________________________________________________________________________________

Do you have a latex allergy? Yes No

Have you been hospitalized during the past five years? Yes No If yes, please describe:

______________________________________________________________________________________

Indicate which of the following you have had, or have at present:

Heart (Surgery, Disease, Attack) Yes No

Chest Pain Yes No

Heart Murmur Yes No

High Blood Pressure Yes No

Mitral Valve Prolapse Yes No

Artificial Heart Valve Yes No

Heart Pacemaker Yes No

Rheumatic Fever Yes No

Arthritis/Rheumatism Yes No

Swollen ankles Yes No

Stroke Yes No

Artificial joints Yes No

Kidney trouble Yes No

Hepatitis A,B,or C Yes No

AIDS Yes No

Blood transfusion Yes No

Sickle Cell disease Yes No

Liver disease Yes No

Neurological disorders Yes No

Fainting or dizzy spells Yes No

Ulcers Yes No

Diabetes Yes No

Thyroid Problems Yes No

Glaucoma Yes No

Emphysema Yes No

Chronic Cough Yes No

Tuberculosis Yes No

Asthma Yes No

Hay Fever Yes No

Sinus trouble Yes No

Radiation Therapy Yes No

Chemotherapy Yes No

Tumors Yes No

Venereal disease Yes No

HIV positive Yes No

Hemophilia Yes No

Bruise easily Yes No

Jaundice Yes No

Epilepsy or Seizures Yes No

Psychological Care Yes No

Have you ever been treated with Botox or Dermal Fillers ( Restylane, Juvaderm)? Yes No

Do you have or have you had any disease, condition or problem not listed? Yes No

If yes, please list: ________________________________________________________________________

Women: Are you pregnant? Yes, ____ months No Are you nursing? Yes No

Taking birth control pills? Yes No

I understand the above information is necessary to provide me with dental care in a safe and efficient

manner. I have answered all questions to the best of my knowledge. Should further information be needed,

you have my permission to ask the respective health care provider or agency, who may release such

information to you. I will notify the doctor of any change in my health or medication.

Patient/Guardian Signature ________________________________________ Date ___________________


* You May Refuse to Sign This Acknowledgment*

I have received a copy of this office’s Notice of Privacy Practices. Print

Name:_______________________________________________________

Signature:____________________________________________________

Date:_______________

For Office Use Only ______________________________________________________________________________ We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

Individual refused to sign

Communications barriers prohibited obtaining the acknowledgement

An emergency situation prevented us from obtaining acknowledgement

Other (Please Specify)

© 2010, 2013 American Dental Association. All Rights Reserved.

Consent for Treatment Form


1. I hereby authorize Dr. Silberman, Dr. Turok, or designated staff to take x-rays, impressions for

study models, photographs, and any other diagnostic aids deemed appropriate by the doctor to

make a thorough diagnosis of (name of patient) ____________________________________’s

needs.

2. Upon such diagnosis, I authorize Dr. Silberman or Dr.Turok to perform all recommended

treatment mutually agreed upon by me and to employ such assistance as required to provide

proper care.

3. I agree to the use of anesthetics, sedatives and other medication as necessary. I fully

understand that using anesthetic agents embodies certain risks. I understand that I can ask

for a complete recital of any possible complications.

4. There is a fee of $55 per appointment hour for any missed appointment and/or cancelled

appointment with less than 48 hours notice.

5. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

I understand that payment is due at the time of service unless other arrangements have been

made in advance.

Patient Signature _______________________________________Date__________________

Responsible Party ____________________________________________________________

Relationship to Patient _________________________________________________________

patient registration form today’s date s m p d...

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