Dr. Ted Im DDS

23205 Sunnymead Blvd, Moreno Valley, CA 92553

951-242-6242

WELCOME TO IMAGE DENTISTRY

Patient Registration and Medical History

Date
Last Name
First Name
Middle Initial
Preferred Name
Street Address
City
State
Zip
Cell Phone
Home Phone
E‐mail
Sex
Birth Date:
Marital Status
Occupation
Employer
Address
Work Phone
Spouse Name
Spouse Employer
Address
Work Phone
Who is Responsible for this account?
Relationship to Patient
Name of Dental Insurance
Group #
Name of Insured/Policy Holder
Social Security #
DOB
Are you covered by another Dental Insurance?
If YES:
Name of Dental Insurance
Group #
Name of Insured/Policy Holder
Social Security #
DOB
Emergency Contact
Relationship
Phone
Whom may we thank for referring you?
DATE
CHANGES
INITIALS
DATE
CHANGES
INITIALS

Authorization: I authorize my insurance company to pay to the dentist or dental group all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions. I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.

Patient's Signature:

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

Date:

Payment is due in full at the time of treatment unless prior arrangements have been approved.

IMPORTANT MEDICAL ALERT

A connection between Fosamax and other bisphosphonates with a serious bone disease called Osteonecrosis of Jaw (ONJ) has been found. Bisphosphonates are commonly used in tablet form to prevent and treat osteoporosis in post-menopausal women. They are also used in the treatment of Paget's disease. Stronger forms given orally or intravenously (IV) are commonly used in the management of advanced cancers including, but not limited to, lung cancer, breast cancer, prostate cancer & multiple myeloma.

Have you taken any of the following bisphosphonates?

Alendronate (Fosomax®)
Clodronate (Bonefos®, Ostac®)
Etidronate (Didronel®)
Ibandronate (Boniva®)
Parnidronate (Aredia®)
Raloxifene (Evista®)
Risedronate (Actonel®)
Teriparatide (Forteo®)
Tiludronate (Skelid®)
Zoledronate (Zometa®)
If yes, when?
Prescribing Doctor
Phone

MEDICAL HISTORY

Physician's Name
Phone
Date of Last Physical
Are you under the care of a physician?
If yes: For what conditions?

Have you ever had any of the following? (Please check Yes or No)

Allergies
Emphysema
Nervous Problems
Anemia
Epilepsy
Pacemaker
Arthritis
Fainting
Psychiatric care
Artificial Heart Valves
Glaucoma
Radiation Treatment
Asthma
Headaches
Recent Weight Loss
Autism
Heart Attack
Respiratory problems
Back Problems
Heart Murmur
Rheumatic Fever
Bleeding Abnormally
Heart Problems
Seizures
Blood Disease
Hemophilia
Sinus Problems
Cancer
Hepatitis or Jaundice
Special Diet
Cardiac Pacemaker
High Blood Pressure
Stroke
Chemical Dependency
HIV/AIDS
Swollen Neck Glands
Chest Pains
Joint Replacement
Thyroid problems
Chronic Diarrhea
Leukemia
Tuberculosis
Circulatory Problems
Liver Disease
Ulcer
Congenital Heart Lesions
Low Blood Pressure
Venereal Disease
Diabetes
Mitral Valve Prolapse
Other:

Are you allergic to or have you had any reaction to the following?

Local anesthetics (eg. Novocain)
Codeine
Penicillin or other antibiotic
Sedatives
Sulfa Drugs
Latex Allergy
Barbiturates
Iodine
Aspirin
Other:

Women Only

a) Are you pregnant or think you may be pregnant?
b) Are you nursing?
c) Are you taking birth control pills?
Is there anything else we should know about your medical history?

I certify that I have read and understand the above information. To the best of my knowledge the above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health.

Patient's Signature:

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

Date:

Guardian's Signature:

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Date:

Doctor's Signature:

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

Date: