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Hebron Smiles

Patient Registration Information

*Patient Name:

First name

Last name

Birthday:		Age:
Social Security #:

*Home Address:

				City
State		Zip		APT#

*Home Phone #:

()- -

Cell Phone#:

()- -

*Email Address:

Referred By:

Preferred Pharmacy:

Contact Details In Case of Emergency -

His/Her Name:

Phone #:

()- -

Insurance Information

Primary Insurance -

Insured’s name:

Social Security #:

Relationship to insured:

Insured’s employer:

Address:

				City
State		Zip		APT#

Ins. Company:

Secondary Insurance -

Insured’s name:

Social Security #:

Relationship to insured:

Insured’s employer:

Address:

				City
State		Zip		APT#

Ins. Company:

*Signature:		Date:
(Your digital signature (full name) is as legally binding as a physical signature.)

Are you under a physician’s care now?	Yes No
Have you ever being hospitalized or had a major operation?	Yes No
Have you ever being in a serious neck/head injury?	Yes No
Are you taking any medication, Pills or Drugs?	Yes No
Have you ever taken Fosamax,Bonivia,Actonel or any other medication Containing bisphosphonates?	Yes No
Are you on a special diet?	Yes No
Do you use tobacco?	Yes No
Do you use controlled substance?	Yes No
Women : Are you Pregnant?	Yes No
Women : Taking Oral Contraceptives?	Yes No
Women : Nursing?	Yes No


*	To the best of my knowledge, the question on his form has been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the dental office of any changes in medical status.

Patient Registration Information

Insurance Information

Medical History