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
Birth Date
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

Patient Name:
Birth Date:
Date Created:

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Are you under a physician's care now?
If Yes
Have you ever been hospitalized or had a major operation?
If Yes
Have you ever had a serious head or neck injury?
If Yes
Are you taking any medications, pills, or drugs?
If Yes
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
If Yes
Do you use tobacco of any type?
If Yes
Do you use controlled substances?
If Yes
Do you need premedication prior to dental treatment ?
If Yes

Women: Are you ...

Pregnant / Trying to get pregnant?
Nursing?
Taking oral contraceptives?

Are you allergic to any of the following?

If Yes

Do you have, or have you had, any of the following?

ADD/ADHD
AIDS/ HIV Positive
Alzheimer
Anaphylaxis
Anemia
Angina
Anxiety
Arthritis / Gout
Artificial Heart Valve
Artificial Joint
Asthma
Blood Disease
Blood Transfusion
Breathing Problems
Bruise Easily
Cancer
Chemotherapy
Cold Sores / Fever Blisters
Congenital Heart Disorder
Diabetes Type I
Diabetes Type II
Drug Addiction
Emphysema
Epilepsy or Seizures
Excessive Bleeding
Genital Herpes
Heart Attack / Failure
Heart Murmur
Heart Pacemaker
Hepatitis A
Hepatitis B or C
Herpes
High Blood Pressure B
High Cholesterol
Kidney Problems
Leukemia
Liver Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse
Mitral Valve Prolapse
Osteoporosis
Pain in Jaw Joints
Parkinsons Disease
Psychiatric Care
Radiation Treatments
Respitory Disease
Rheumatic Fever
Rheumatism
Seasonal Allergies
Shingles
Sickle Cell Disease
Sinus Trouble
Stomach / Intestinal Disease
Stroke
Thyroid Disease
Tuberculosis
Ulcers
Venereal Disease
Yellow Jaundice
Have you ever had any serious illness not listed
If Yes

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

SIGNATURE OF PATIENT, PARENT, or GUARDIAN:

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

Date:
Comments:

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:

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

Date: