Thomas N. Pezdek DDS PA

412-D East Williams St. Apex, NC 27502

919-372-3887

PATIENT REGISTRATION AND MEDICAL HISTORY

Date
Home Phone
Patient Name:
Street Address
City
State
Zip
E-mail
Cell Phone
Sex
Age
Birthdate
If Partnered for how many years?
Employer/ School
Occupation
Employer /School Address
Employer/ School Phone
Spouse/Parent Name
Spouse/ Parent Birthdate
Spouse/Parent Employed by
Occupation
Business Address
Business Phone
Who is responsible for this account?
Relationship to Patient
Social Security#
Spouse/ Parent's Social Security #
Name of Dental Insurance Company
Group Number
In case of emergency, who should be notified?
Phone
Whom may we thank for referring you?

MEDICAL HISTORY

Physician 's Name
Date of Last Physical

Have you ever had any of the following? (check boxes that apply):

Do you have any drug allergies or have you ever had an adverse reaction to any medication or anesthesia?
If so, what?
Have you ever responded adversely to medical or dental treatment?
Are you taking any medication at this time?
If so, what?
Have you ever taken any of the group of drugs collectively referred to as "fen -phen?" These include combinations of lonimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine.)
Are you under the care of a physician?
For what conditions?
If patient is a child, what is his/ her weight?

Women

Do you suspect that you are pregnant?
Due date
Are you nursing?
Taking birth control pills?
Is there anything else we should know about your medical history?

CERTIFICATION

To the best of my knowledge, the information provided on this form is complete and correct. I understand that it is my responsibility to inform my doctor if my minor child ever has a change in health.

MINOR/CHILD CONSENT

I am the parent , guardian, or personal representative of and there are no court orders now in effect that prohibit me from signing this consent. I do hereby request and authorize the dental staff to perform necessary dental services for the child named above, including but not limited to x-rays, and administration of anesthetics, which are deemed advisable by the doctor, whether or not I am present when the treatment is rendered .

INSURANCE ASSIGNMENT AND RELEASE

I certify that my dependent(s) is covered by insurance with and assign directly to Dr. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above named doctor may use my minor/ child's health care information and may disclose such information to the above named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when the current treatment plan is completed or one year from the date signed below.

FINANCIAL AGREEMENT

I acknowledge that payment is due at the time of treatment, unless other arrangements are made. I agree that parents, guardians or personal representatives are responsible for all fees and services rendered for treatment of a minor/ child. I accept full financial responsibility for all charges for services or items provided to me or the patient. I understand that filing a claim with my insurance company does not relieve me from my responsibility for the payment of all charges.

Patient's Signature:

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Date:

Guardian's Signature:

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Relationship to Patient

MEDICAL HISTORY UPDATE

Has there been any change in the patient's health since the last dental appointment?
For what conditions?
Is the patient taking any new medications?
If so, what?

Patient's Signature:

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Date:

Doctor's Signature:

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Date:

MEDICAL HISTORY UPDATE

Has there been any change in the patient's health since the last dental appointment?
For what conditions?
Is the patient taking any new medications?
If so, what?

Patient's Signature:

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

Date:

Doctor's Signature:

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Date: