Jeannette M Pope-Ozimba D.D.S.

1505 West 3rd Ave, Suite A, Albany, Georgia, 31707, USA

229-435-6161

Dental Patient Registration

DENTAL HISTORY

Name:
E‐mail:
Phone:
Former Dentist
Date of Last X-rays
City, State
How Often Do You Floss?
Date of Last Dental Visit
How Often Do You Brush?
What is your main source of drinking water?
Please answer Yes to all that apply:
Bad Breath
Loose Teeth or Broken Fillings
Sensitivity to Sweets
Bleeding Gums
Orthodontic Treatment
Sensitivity When Biting
Blisters on Lips or Mouth
Pain Around Ear
Frequent Headaches
Finger Nail Biting
Periodontal Treatment
Jaw, Head or Neck Injuries
Grinding Teeth
Sensitivity to Cold
Jaw Difficulty: Clicking and/or pain
Lip or Cheek Biting
Sensitivity to Heat
Tooth Pain

MEDICAL HISTORY

Physician Name:
Date of Last Visit
Please answer Yes or No to the following questions:
1. Are you currently under medical treatment?
2. Have you ever had any serious illness or operations?
3. Are you currently taking any medication?
Please describe
4. Do you smoke?
5. Do you use alcohol, cocaine, or other drugs?
6. Do you wear contact lenses?
7. (Females Only) Are you:
Pregnant?
Nursing?
Taking birth control pills?
8. Have you had any allergic reactions to:
9. Local Anesthetics (e.g. Novocaine)
10. Penicillin or other Antibiotics
11. Sulfa Drugs
12. Barbiturates
13. Sedatives
14. Iodine
15. Aspirin
16. Other:
Please answer Yes or No to each:
Acid Reflux
ADHD
AIDS
Anemia
Arthritis Rheumatism
Artificial Heart Valves
Artificial Joints
Aperger‛s Syndrome
Asthma
Autism
Back Problems
Bleeding Abnormally with
Extractions or Surgery
Blind
Blood disease
Cancer
Cerebral Palsy
Chemical dependency
Chemotherapy
Congenital Heart Lesions
Cortisone Treatments
Cough-persistent / bloody
Developmental Disorder
Diabetes
Down's Syndrome
Epilepsy
Fainting or Dizziness
Glaucoma
Headaches
Hearing Impaired
Heart Murmur
Heart Problems
Hepatitis
Type
Herpes
High Blood Pressure
HIV Positive
Jaundice
Kidney Disease
Liver Disease
Low Blood Pressure
Mental Disorder
Mitral Valve Prolapse
Nervous Problems
Pervasive Developmental Disorder (PDD)
Psychiatric Care
Radiation Treatment
Respiratory Disease
Rheumatic Fever
Scarlet Fever
Scoliosis
Seizures
Shortness of Breath
Sickle Cell Anemia
Sinus Trouble
Skin Trouble
Spinal Bifida
Stroke
Swollen Neck Glands
Thyroid Problems
Tonsillitis
Tourette‛s Syndrome
Tuberculosis
Tumor or growth on Head/Neck
Other

ASSIGNMENT AND RELEASE

I hereby authorize payment directly to Dr. Pope-Ozimba for all insurance benefits otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, whether or not paid by insurance, and for all services rendered on my behalf or my dependents. I authorize the above Dr. and/or any provider or supplier of services in this office to release the information required to secure payment of benefits. I authorize the use of this signature on all insurance submissions.

Signature of Responsible Party

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Responsible Party Name
Date

PATIENT INFORMATION

Date
Soc. Sec#
Birth date
Name
Sex:
Address
City
State
Zip
Home Phone
Cell Phone
Email Address
Best time to call
Whom may we thank for referring you?
In case of emergency, who should we contact?
Phone

PARENT’S INFORMATION

Name
Relationship to patient
Birth date
Soc Sec #
Address
Home Phone
City
State
Zip
Employer:
Business Phone
Business Address
Occupation

DENTAL INSURANCE

Person Responsible for Account
Relationship to patient:
Birth date
Soc Sec#
Address
Home Phone
City
State
Zip
Responsible Party Employed By
Business Phone
Business Address
Occupation
Insurance Company
Insurance Company Address
Subscriber I.D. #
Group #

Patient's Signature:

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Date:

Guardian's Signature:

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Name:
Date:

Doctor's Signature:

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Name:
Date: