Dr. Myung Hae Hyon & Dr. Mrunal J Patel

924 N.Wood Ave Linden, NJ 07036

908-925-8110

WEB PATIENT REGISTRATION

Responsible Party
First Name:
Last Name:
Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Ext:
Pager:
Cellular:
Birth Date:
Social Security:
Drivers Lic:
Patient Information
First Name:
Last Name:
Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Pager:
Ext:
Cellular:
Gender
Marital Status:
Birth Date:
Age:
Social Security:
Drivers Lic:
Email:

Primary Insurance Information
Name of Insured
Relationship to Insured:
Insured Social Security
Insured Birth Date
Employer
Address
Address 2
City, State, Zip
Rem. Benifits .00
Ins. Company:
Address
Address 2
City, State, Zip
Rem. Deduct .00
Secondary Insurance Information
Name of Insured
Relationship to Insured:
Insured Social Security
Insured Birth Date
Employer
Address
Address 2
City, State, Zip
Rem. Benifits .00
Ins. Company:
Address
Address 2
City, State, Zip
Rem. Deduct .00

Our office requires 24 Hours to cancel/ change appointment. If proper notice is not given a broken appointment fee will be charged.

Cell phones or pagers are permitted on in waiting room ONLY.

WEB PATIENT MEDICAL HISTORY

Please answer all questions. Answers to the following questions are for our records only and will be considered confidential.

Are you in good health?
Has there been any change in your general health?
Your last physical examination was on
Are you now under the care of a physician?
Name and address of your physician
Have you ever had a serious illness or operation?
Have you been hospitalized with any of the following within the last 5 years?
Did you have a persistent cough or cough up blood?
Low blood pressure
High blood pressure
Venereal Disease
AIDS or HIV
Others
Have you had abnormal bleeding associated with previous extractions, surgery, or trauma?
Do you bruise easily?
Have you ever required a blood transfusion
If yes, explain the circumstances
Do you have any blood disorder such as anemia?
Have you had surgery or x‐ray treatment for a tumor, growth or other condition of your mouth or lips?

Medications

Are you taking any drug or medication?
If yes, what?
Are you taking any of the following?
Antibiotics or sulfa drugs
Anticoagulants (blood thinners such as Coumadin, Plavix etc)
Medicine for high blood pressure
Cortisone (steroids)
Tranquilizers
Aspirin
Insulin, Tolbutamide (Orinase) or similar drug
Digitalis or drugs for heart trouble
Nitroglycerin
Fen‐Phen (now or in the past) or related drug such as Ionimin, Adipex, Phentermine, Fastin, Pondimin (Fenfluramine), and Redux (dexfenfluramine)
Oral Contraceptives
If Yes, what are you using?
Chemotherapy Drugs
Osteoporosis Drugs (Fosamax, Aredia, Zometa etc.)
Any natural product, herbal supplement or homeopathic remedy?
Others

Habits

Do you smoke?
If Yes, how much?
Do you drink alcoholic beverages?
Do you take any recreational drugs?

Do you have any of the following?

Cardiac pacemaker
Implants/Artificial prosthesis (Knee joints, elbow pins etc)
A removable dental appliance

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

Rheumatic fever or rheumatic heart disease
Heart Murmur or mitral valve prolapse
Congenital heart lesions
Cardiovascular disease (heart trouble, heart attack, coronary occlusion, high blood pressure, arteriosclerosis, stroke)
Do you have pain in the chest upon exertion?
Are you ever short of breath after mild exercise?
Do you get short of breath when you lie down or do you require extra pillows when you sleep?
Hepatitis, jaundice, or liver disease
Convulsions/ Epilepsy
Stroke
Asthma or hay fever
Hives or skin rash
Fainting spells or seizures
Diabetes
Do you have to urinate (pass water) more than six (6) times a day?
Are you thirsty much of the time?
Does your mouth frequently become dry?
Arthritis
Inflammatory rheumatism (painful, swollen joints)
Stomach ulcers
Kidney trouble
Tuberculosis
Are you immunosuppressed? Possibly from transplant surgery
A tumor or growth
Radiation therapy or chemotherapy
Thyroid trouble
Bleeding tendency /abnormal bleeding

ALLERGY

Are you allergic or have you reacted adversely to:
Local anesthetic
Penicillin or other antibiotics (such as amoxicillin, clindamycin, erythromycin, Keflex etc)
Barbiturates, sedatives, or sleeping pills
Sulfa Drugs
Codeine
Valium or other tranquilizer
Aspirin
Iodine
Latex
Other
Have you had any serious trouble associated with previous dental treatment?
If yes, explain

For Women Only

Are you pregnant or could you be?
If yes, when are you due?
Are you nursing?
Are you taking oral contraceptives?

I certify to the best of my knowledge that the above information is correct and that if there are any changes in the above, I agree to notify my dentist before my next visit.

Patient's Signature

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Date:

Guardian's Signature:

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Doctor's Signature:

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Date: