Patient registration

Patient Contact Information
 Single  Married  Domestic Partner Whom may we thank for referring you to our office? Person responsible for payment of this account: Dental Insurance Information

As dental care providers, we want to emphasize that our relationship is with you, not your insurance company. While the
filing of insurance claims is a courtesy that we extend to our patients, all charges and payments are your responsibility
from the date that services are rendered. We encourage you to read and understand your particular dental policy. By
signing below, you authorize the Itani Dental, Inc. to submit charges to your credit card on file to cover balances due 60
days or more.

Patient/Guardian Signature:
Medical Insurance (for Hospital Patients):
Patient Health History
1. Have you been under the care of a physician in the past 2 years? Physician name: ______________________________________________________ Phone:
Are you currently taking any medications? If yes, please list name, dosage & medical condition: 3. Have you ever had an allergic reaction to any medications? If yes, please list medication & effects: Are you taking anticoagulant medications? ( Coumadin, Warfarin, Plavix, Ticlid, Heparin) If yes, name of medication? _____________________________ how long taken? ___________________ Are you taking or have you ever taken bisphosponate drugs? (such as Fosamax, Zometa, Boniva, Actonel, Didronel, Aredia, Skelid ) Yes ______ If yes, medication name? ________________________ I.V. 0ral? how long taken? _________ 4. Women, please answer the following additional questions: Taking birth control pills? Yes____ No____ 5. Do you have or have you ever had any of the following: Do you have or have you had any disease, condition or problem not on this list? If yes, please describe:
I understand that the information gathered on this medical history form is intended to help inform the Blende Dental 20Group
staff of any pre-existing medical conditions so that the best course of treatment can be determined. I understand that failure to
disclose this information could affect my own safety. I affirm that the medical information indicated here is accurate and
complete.
Patient/Guardian Signature:
Health History Updates
Dental History
1. On a scale from 1-10 (10 being highest): a. Where do you rate your dental health now? b. Where would you like your dental health to be in 5 years? 3. Have any of your friends or family had cosmetic dentistry? 4. Do you plan to have cosmetic dentistry in the future? 5. If so, which procedure would you have first? (Choose one) 6. Are you inquiring about having all dental care done under General Anesthesia or I.V. Sedation? 7. Have you previously had dental care using any of the following types of sedation? (Check all that apply) At which dental office did you have treatment under sedation? 8. What is the reason for your visit today? 9. What is the date of your last dental visit? 10. Have you ever had any unsatisfactory experiences with previous dental treatment or providers? 11. Have you ever been treated for periodontal (gum) disease? 12. Have you ever had orthodontic therapy or worn braces? 14. Do you smoke a pipe, cigars, cigarettes or chew tobacco? Circle appropriate product(s) 17. Do you use a standard or electric toothbrush?
18. Do you use a fluoride or plaque rinse? Dental Anxiety Scale
Please answer the following questions by circling the appropriate response. 1. If you had to go to the dentist tomorrow, how would you feel about it?
d. So anxious that I sometimes break out in a sweat or almost feel physically sick. e. I start thinking of ways to cancel the appointment or not show up. 2. When you are waiting in the dentist’s office for your turn in the chair, how do you feel about it?
d. So anxious that I sometimes break out in a sweat or almost feel physically sick. 3. When you are in the chair waiting while the dentist prepares to give you an injection, how do you feel?
d. So anxious that I sometimes break out in a sweat or almost feel physically sick. 4. When you are in the chair waiting while the dentist gets the drill ready to begin working on your teeth, how do you
feel?
d. So anxious that I sometimes break out in a sweat or almost feel physically sick. 5. When you are waiting in the chair while the hygienist is getting out the instruments to scrape your teeth around the
gums, how do you feel?
d. So anxious that I sometimes break out in a sweat or almost feel physically sick. 6. Please rate from 1-7 (1 being most fearful) the following fear-producing stimuli.
Most Fearful
Less Fearful

Source: http://itanidental.com/wp-content/uploads/2010/08/NP_Registration_2010.pdf