Dr. Iván E. Rodriguez

Harlingen Office Address, 1610 East Harrison Ave,

suite A, Harlingen, Texas 78550

956-412-9500

Patient Registration

Drs. Rodriguez, Velez, and Trevino Welcome You

Root canal therapy is an attempt to save a tooth which otherwise may require extraction. We need certain information about you to make treatment as safe and successful as possible. Please read and fill out both sides carefully. If you have questions, be sure they are answered before signing this form.

Patient's Name
Phone
Phone
Address
Apt #
City
State
Zip
Soc. Sec. No
Birth date
Driver's Lic. No
Exp.
Email
If minor, Guardian's name
Birth date
Relationship
Dental Insurance
BCBS ofTX
Name of Employer
Dept.
Work Phone
Ext
Employer's Address
E-MAIL address
Spouse Name
DOB:
Cell Phone::
Spouse's Employer
Employer's Address:
Person to contact in case of an emergency
Phone
Whom may we thank for referring you?

Medical History: please make a check mark whether you now have or have ever been treated for:
General health (make a check mark):
Name of Physician
Date of last Physical examination
Any major change in health during the past year?
Do you have any other medical problem(s) not listed above?
Select if you are allergic to:
Allergies to any other medications, not listed above?
Please list below any medications you are presently taking: (Name, for what condition?)
Explain in your words the reason of today’s visit
Is your visit due to an accident?
If yes, please explain and date of accident

AN X-RAY(S) IS NECESSARY TODAY, TO ESTABLISH A COMPLETE DIAGNOSIS.

Where does it hurt?
Have you had this problem (or similar problem) before?
If yes, please explain
On scale of0-10, where would you rate you discomfort? (10 = most discomfort)
Is it a sharp pain or is it more like a dull ache?
Does it throb, hurt, or is it more of a steady unchanging pain?
Does it hurt all the time or does it start and stop?
Does it interfere with your sleep?
Does anything make the pain worse?
What?
Have you taken aspirin or any other medication?
Does the medication help?

Consent Form:

I have reviewed the health history and believe it to be correct. If there is a change in health or in medications taken, I will inform the doctor at my next appointment. I consent to treatment by the health care providers of this dental practice.

Signature of Patient or (Parent's if minor)

Use your mouse cursor or the tip of your finger to sign below

Date:

Doctor's Signature

Use your mouse cursor or the tip of your finger to sign below

Date:
Assistant's initials
CONSENT TO RECEIVING PRIVACY NOTICE

ASSIGNMENT OF INSURANCE BENEFITS

CONSENT FOR EVALUATION

I was given the opportunity to read the Privacy Notice and object to disclosures of my protected health information.

I authorize that I am financially responsible for all charges whether or not paid by insurance.

I authori ze my insurance company to pay to the dentist all insurance benefits otherwise payable to me for services rendered. l authorize the use of this signature on all insurance submissions.

I authorize the dentist to release all information concerning my health care, advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits.

I permit a copy of this authorization to be used in place of the original.

Patient's Signature or (Parent's if minor)

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Date:
Woman Only
Are you presently pregnant?
Are you presently taking oral contraceptives?

If so, read and sign the following:

Information and consent form patients taking oral contraceptives

It has been explained to me, and I understand, that oral antibiotics (and certain other medications) may interfere with the effectiveness of oral contraceptives. Therefore, I understand that I will need to use some additional form of birth control for one complete cycle of birth control pills after my course of antibiotics or other medication is completed.

Parent's Signature:

Use your mouse cursor or the tip of your finger to sign below

Date: