Lubus Family Dentistry New Patient Registration Form

In order to render an optimum health service it is necessary to obtain a variety of vital personal information. All information obtained is of course confidential. All information that you enter on this form is encrypted for your privacy.
* denotes required field.

Name: Name: First Middle Last
Birthdate: Birthdate: / MM / DD YYYY
Address: Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Phone: Home Phone: - ### - ### ####
Cell Phone: Cell Phone: - ### - ### ####
Work Phone: Work Phone: - ### - ### ####
Email address:
Employer:
Health Card #:
Name of Insurance Company:
Who may we thank for your referral?
Name of Physician:
Phone: Phone: - ### - ### ####
To the best of your knowledge, are you in good health?

To the best of your knowledge, are you in good health? Yes No
Are you presently under treatment or observation by a physician?

Are you presently under treatment or observation by a physician? Yes No
Date of last complete physical examination: Date of last complete physical examination: / MM / DD YYYY
Are you taking any medications prescribed or self-administered?
List your medications here:
1.
Please list your medications separated by commas (,)
Reasons for your medications?
1.
Please list your reason for each medication separated by commas (,)
Have you experienced an unusual reaction to any of the following medications?
Penicillin

Penicillin Yes No
Other Antibiotics

Other Antibiotics Yes No
Aspriin

Aspriin Yes No
Sulfa Drugs

Sulfa Drugs Yes No
Codeine

Codeine Yes No
Local Anesthesia

Local Anesthesia Yes No
Do you have any allergies?
Please list your allergies
1.
Please list your allergies separated by commas
Do you have, or have you had any of the following:
CVS
Heart Murmur

Heart Murmur Yes No
Heart Disease

Heart Disease Yes No
Chest Pains

Chest Pains Yes No
Shortness of breath

Shortness of breath Yes No
Swelling of the ankles

Swelling of the ankles Yes No
Abnormal blood pressure

Abnormal blood pressure Yes No
Headaches

Headaches Yes No
Blood Abnormalities
Tested positive for HIV

Tested positive for HIV Yes No
Tend to bruise / bleed easily

Tend to bruise / bleed easily Yes No
Prolonged bleeding episodes

Prolonged bleeding episodes Yes No
Blood disorders

Blood disorders Yes No
Had blood transfusion

Had blood transfusion Yes No
Respiratory Disease
Sinusitis

Sinusitis Yes No
Asthma

Asthma Yes No
Bronchitis

Bronchitis Yes No
Tuberculosis

Tuberculosis Yes No
CNS
Epilepsy

Epilepsy Yes No
Tendency to faint

Tendency to faint Yes No
Fits or convulsions

Fits or convulsions Yes No
Kidney Disease
Recurring kidney infections

Recurring kidney infections Yes No
Kidney Stone

Kidney Stone Yes No
Void more than 6X / day

Void more than 6X / day Yes No
Liver Disease
Cirrhosis

Cirrhosis Yes No
Jaundice

Jaundice Yes No
Hepatitis

Hepatitis Yes No
G.I. Disease
Food intolerances

Food intolerances Yes No
Medicine intolerances

Medicine intolerances Yes No
Ulcers

Ulcers Yes No
Endocrine
Diabetes

Diabetes Yes No
Thyroid problems

Thyroid problems Yes No
Weight loss in short period of time

Weight loss in short period of time Yes No
Ocular Diseases
Glaucoma

Glaucoma Yes No
Frequent eye problems

Frequent eye problems Yes No
Women Only
Are you pregnant?
If yes, in what stage of pregnancy?
Are you taking oral contraceptives / hormones?

Are you taking oral contraceptives / hormones? Yes No
Have you ever been hospitalized?
Year
Hospital
Dr. In Charge
Purpose of stay
I believe the above information to be true and correct. I authorize the Doctor and the assistants that he delegates to perform any dental and oral surgical procedures including the use of radiography (X-rays) and drugs, that he feels necessary for my oral health, and I assume the responsibility for fees associated with those procedures.
Date Date / MM / DD YYYY
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.

Lubus Family Dentistry New Patient Registration Form

Lubus Family Dentistry New Patient Registration Form

Have you experienced an unusual reaction to any of the following medications?

Do you have, or have you had any of the following: CVS

Blood Abnormalities

Respiratory Disease

CNS

Kidney Disease

Liver Disease

G.I. Disease

Endocrine

Ocular Diseases

Women Only

Do you have, or have you had any of the following:
CVS