NORTH TEXAS DENTAL CENTER
New Patient Registration Form

Please note:  For security of information all data supplied on this form is sent by SSL encryption
PATIENT INFORMATION
First Name:
Middle Initial:
Last Name:
Preferred Name:
Street Address:
City:
State:
Zip:
Driver's License
State & #:
Sex: Male     Female
Date of Birth:
Social Security #:
Email:
Single      Married      Divorced     Widowed
Home Phone:
Business Phone:
Ext:
Mobile Phone:
How do you prefer to be contacted? Home Phone      Cell Phone
Work Phone      Email
Whom may we thank for referring you?:
Emergency Contact
Name:
Address:
City, ST, Zip:
Home Phone:
Business Phone:
Mobile Phone:
How do you prefer to be contacted?  Home Phone      Cell Phone      Email
ACCOUNT RESPONSIBILITY / INSURANCE CARD HOLDER

Who will be responsible for your account? (If patient is a minor)
Self      Spouse     Father     Mother     Other (please specify below)

Title: Mr.      Mrs.      Ms.     Dr.
First Name:
Middle Initial:
Last Name:
Street Address:
City:
State:
Zip:
Relationship
Daytime Phone:
Home Phone:
Mobile Phone:
Employer Name:
Business Phone:
(if other) Relation:
PRIMARY DENTAL INSURANCE
Ins. Co. Name:
Phone:
Employer:
Address:
Group #:
Subscriber Name:
Subscriber Date Of Birth:
SSN/ID #:
SECONDARY DENTAL INSURANCE
Ins. Co. Name:
Phone:
Employer:
Address:
Group #:
Subscriber Name:
Subscriber Date Of Birth:
SSN/ID #:
GENERAL HEALTH

Age:        Height:       Weight:

Physician:
Are you taking any medications? Yes    No  
If yes, list medications
Are you allergic to any medications? Yes    No  
If yes, list medications
Other Medical Problems
Problems with previous General Anesthesia/IV Sedation?  Yes    No
If yes, what was the problem? 
Do you smoke?  Yes    No   If yes, How many packs per day?      If yes, How many years?
Do you chew/dip?  Yes    No   If yes, How much per day?      If yes, How many years?
Are there any other conditions concerning your health that your doctor should be aware of?
If you have had a tumor/cancer, where ?
If you have had radiation/chemotherapy, where?
GENERAL HEALTH HISTORY
Have you ever responded adversely to medical or dental treatment? Yes    No
Have you ever taken any of the group of drugs collectively referred to as "fen-phen"?  These include combinations of Ionimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine), and Redux (dexfenfluramine). Yes    No

Do you take blood thinners, Aspirin, or Aspirin-containing products?
If yes, How much and how often?

Yes    No
Have you ever been treated with Cortisone, Prednisone, or other steroids?
If yes, When? 		Yes    No
Are you under the care of a physician at this time?
If yes, for what conditions? 		Yes    No
CONDITIONS  All responses are kept strictly confidential.
AIDS/HIV Yes    No
Allergies/Hay Fever Yes    No
Anemia Yes    No
Angina Pectoris Yes    No
Arthritis/Rheumatism Yes    No
Artificial Heart Valve Yes    No
Artificial Joints/Screws Yes    No
Asthma Yes    No
Back Problems Yes    No
Bleeding Abnormally Yes    No
Blood Disease Yes    No
Blood Transfusion Yes    No
Cancer Yes    No
Chemical Dependency Yes    No
Chemotherapy Yes    No
Circulatory Problems Yes    No
Cold Sores Yes    No
Congenital Heart Lesions Yes    No
Cortisone Treatments Yes    No
Cosmetic Surgery Yes    No
Cough, consistent or bloody Yes    No
Diabetes Type I or II Yes    No
Drug Abuse History Yes    No
Emphysema Yes    No
Epilepsy/Seizures Yes    No
Fainting/Dizziness Yes    No
Gastro-Esophageal Reflux Yes    No
Glaucoma Yes    No
Headaches Yes    No
Heart Disease Yes    No
:Heart Murmur Yes    No
Hepatitis A/B/C Yes    No
Herpes Yes    No
High Blood Pressure Yes    No
High Cholesterol Yes    No
Jaundice Yes    No
Jaw Pain Yes    No
Kidney Disease Yes    No
Liver Disease Yes    No
Low Blood Pressure Yes    No
Mitral Valve Prolapse Yes    No
Nervous Problems Yes    No
Pacemaker Yes    No
Psychiatric Care Yes    No
Radiation Treatment Yes    No
Respiratory Disease Yes    No
Rheumatic Fever Yes    No
Scarlet Fever Yes    No
Shortness of Breath Yes    No
Sinus Trouble Yes    No
Stroke Yes    No
Swollen Feet or Ankles Yes    No
Swollen Neck Glands Yes    No
Thyroid Problems Yes    No
Tuberculosis Yes    No
Tumor/Growth on Head/Neck Yes    No
Ulcers/Colitis Yes    No
Venereal Disease Yes    No
Weight Loss, Unexplained Yes    No
MEDICATIONS & ALLERGIES
Have you taken any drug for Osteoporosis? Yes    No
Have You EVER taken Arendia? Yes    No
Have You EVER taken Zometa? Yes    No
Have You EVER taken Fosamax? Yes    No
Have You EVER taken Ostac? Yes    No
Have You EVER taken Actonel? Yes    No
Have You EVER taken Skelid? Yes    No
Have You EVER taken Boniva? Yes    No
Have You EVER taken Didronel? Yes    No
ALLERGIES TO MEDICATIONS
Are you allergic to Latex ? Yes    No
Are you allergic to Soy or Egg? Yes    No
WOMEN ONLY
Are you pregnant ? Yes    No
Are you nursing? Yes    No
Are you taking Birth Control Pills? Yes    No
PLEASE READ THEN MARK AS READ
Payment is expected at the time services are rendered.  A pre-determination of your insurance benefits and coverage will be obtained by this office prior to any treatment; however, this is based upon information received from your insurance company and is not a guarantee of payment.  It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid by, or denied by, your insurance company.
I hereby authorize the release of information necessary to process the claim(s).  I authorize the use of this signature on all of my insurance claims, manual or electronic.  I further authorize payment to North Texas Dental Care the benefits otherwise payable to me.  I understand that I am responsible for the payment of services rendered in full, regardless of payments expected by an insurance company.
I hereby give my consent to Jeffery Nelson, D.D.S., M.A.G.D for any diagnostic aids necessary to evaluate, document and/or diagnose my condition.  These shall include, but are not limited to radiographs. models, and photographs.  I further give Dr. Nelson permission to use such date in any future research or publication.  I also release to Dr. Nelson any medical or dental information necessary to evaluate and/or treat my condition.
I have read and fully understand the above medical questionnaire.  I acknowledge that all answers have been recorded truthfully.  I will not hold Dr. Nelson, or any member of the staff, responsible for any errors or omissions that I have made in the completion of this form.