Choice Family Dentistry
Patient Registration and Medical History
Patient Name _______________________________________________ Date of Birth _____________________ Sex: M____ F____
Address ______________________________________ City ________________________ State _______ Zip code ______________
Home Phone _______________________ Cell Phone _______________________ Email ___________________________________
Ins. Person’s Name _______________________________ SS # ____________________________ Ins’d. D.O.B _________________
Employer _______________________________ Ins. Name ___________________________ Group Num. _____________________
Do you have dual coverage? Yes _____ No ____ (If yes, please complete the following information)
Insured Person’s Name __________________________ ID # ____________________________ Ins’d. D.O.B. __________________
Employer _______________________________ Ins. Name____________________________ Group Num. _____________________
Who is responsible for this account? ____________________________________ Social Security # ____________________________
Emergency Contact _____________________________ Relation to patient _______________ Phone# ________________________
Physicians Name __________________________________________________ Phone ______________________________________
MEDICAL HISTORY
Please indicate Yes or No for each of the following that apply now or have applied in the past….
Allergies
Y/N
Chronic Diarrhea
Y/N
Hernia Repair
Y/N
Anemia
Y/N
Circulatory Problems
Y/N
High Blood Pressure
Y/N
Arthritis
Y/N
Congenital Heart Lesions Y/N
HIV/AIDS
Y/N
Artificial heart valves
Y/N
Diabetes
Y/N
Liver Disease
Y/N
Artificial joints, screws Y/N
Epilepsy or seizures
Y/N
Low Blood Pressure
Y/N
Asthma
Y/N
Fainting/Dizzy spells
Y/N
Mitral Valve Prolapse
Y/N
Back Problems
Y/N
Headaches
Y/N
Nervous Problems
Y/N
Bleeding Abnormally
Y/N
Heart Murmur
Y/N
Pacemaker
Y/N
Blood Disease
Y/N
Heart Problems
Y/N
Prosthetics/metal plates
Y/N
Cancer
Y/N
Hemophilia
Y/N
Psychiatric Care
Y/N
Chemical Dependency Y/N Hepatitis, Jaundice
Y/N
Recent Weight Loss
Y/N
Respiratory Disease
Rheumatic Fever
Sinus Problems
Special Diet
Stroke
Swollen Neck Glands
Tumors
Thyroid Problems
Ulcer
Venereal Disease
Tobacco Use
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Why are you now seeking dental treatment? _______________________________________________________________________
Do you have any drug allergies or have you ever had an adverse reaction to any medication or anesthesia? Yes _____ No______
If so, what? __________________________________________________________________________________________________
Are you taking or have you ever taken Bisphosphonates for osteoporosis, multiple myeloma or other cancers (Reclast, Fosamax,
Actonel, Boniva, Aredia, Zometa? Yes_____ No _____
ARE YOU ALLERGIC TO OR HAVE YOU HAD AN ADVERSE REACTION TO: Latex or Rubber products? Yes_____ No_____
Have you ever responded adversely to medical or dental treatment? Yes______ No_____
Are you taking any medication at this time? ________ If so, what? ______________________________________________________
Have you ever taken any group of drugs collectively referred to as “Fen-Phen”? These include combinations of Ionimin, Adipex,
Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine). Yes_______ No______
Are you under the care of a physician? Yes____ No____ For what conditions? _____________________________________________
(Women) Are you pregnant or suspect of pregnancy? Yes_____ No_____ Due Date _______________________________________
Are you nursing? Yes______ No______
Taking birth control pills? Yes_____ No_____
Is there anything else we should know about your medical history? _____________________________________________________
_______________________________________________
Review Medical History- Drs. Signature
1688 N. Perris Blvd., G-1
Perris, CA 92571
951-940-5771
____________________________________________________
Patient or Guardian Signature- Date
10570 Foothill Blvd., #240
Rancho Cucamonga, CA 91730
909-948-2000
It is our goal to make your dental visit the most pleasant and provide the best possible treatment for you.
Please read the following and consult with our team members if any questions arise.
I give permission for x-rays and comprehensive dental examination.
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I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on
the teeth that were not discovered during examination or after tooth has been treated, e.g. root canal therapy following routine
restorative procedures. I give permission to the Dentist to make any/all changes and additions as necessary.
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Choice Family Dentistry will at its option, repair or replace at no cost to patient, only if patient follows prescribed oral health
maintenance visits every 3-6 months by Dentist/Hygienist. This warranty will be void if the need of repair/replacement incurred due
to accident, abuse and/ or failure to maintain the re-care visits as recommended. Minor restorative, e.g. fillings, will uphold a 9
month limited warranty and major restorative, e.g. crowns, will uphold a 15 month limited warranty. For additional information,
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contact Choice Family Dentistry.
We take care to place you at any appointment that fits your schedule as well as the doctor’s schedule, so that we may utilize each
visit to its fullest. Therefore as a courtesy, we ask that you notify us of any appointment cancellations 48 hours in advance. We also
ask that you arrive on time. Except in the case of an emergency, a charge of $50.00 per hour scheduled will be applied to your
account for cancellations that are less than 48 hours and/or no shows. Longer appointments will be pro-rated. We reserve the
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right to reschedule any appointments.
If you have employee dental benefits, we want to help you in every way to make sure you utilize the maximum benefits that your
insurance allows. In order to be successful, we would appreciate prior notification if there are any changes with your insurance
policy such as; employer/group name change, eligibility/termination change on the policy or if your insurance request additional
Initials_____________
information from you.
According to the new federal and state law HIPPA (Health Insurance Portability And Accountability Act), we may use or disclose your
health information only for treatment, payment, health care operation, appointment reminders or when required by law.
Initials_____________
Signature of Patient ___________________________________________ Date____________________
Signature of Parent/Guardian________________________________________________
Date ___________________
1688 N. Perris Blvd., G-1
10570 Foothill Blvd., #240
Perris, CA 92571
Rancho Cucamonga, CA 91730
951-940-5771
909-948-2000