Fill Out Form Patient Registration

First Name

Last Name

Preferred Name

Gender Male Female

Date Of Birth

Driver's License Number

SSN

Address

Address (optional)

Primary Phone

Work Phone

Emergency Phone

Employer

Occupation

Employment Status

First Name

Last Name

Preferred Name

Gender Male Female

Date Of Birth

Driver's License Number

SSN

Address

Address (optional)

Primary Phone

Work Phone

Emergency Phone

Employer

Occupation

Employment Status

Insurance Company Name

SSN or ID Number

Group Number

First Name

Last Name

Preferred Name

Gender Male Female

Address

Address (optional)

Employer

Occupation

Employment Status

Insurance Company Name

SSN or ID Number

Group Number

First Name

Last Name

Preferred Name

Gender Male Female

Address

Address (optional)

Employer

Occupation

Employment Status

Are you currently being treated by a physician? Yes No

If Yes:

Have you ever been hospitalized or had a major operation? Yes No

If Yes:

Have you ever had a serious head or neck injury? Yes No

If Yes:

Are you taking any medications, pills, or drugs? Yes No

If Yes:

Do you take, or have you taken, Phen-Fen or Redux? Yes No

If Yes:

Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? Yes No

If Yes:

Are you on a special diet? Yes No

If Yes:

Do you use tobacco? Yes No

Do you use controlled substances? Yes No

If Yes:

Women: Are you pregnant / Trying to get pregnant? Yes No

Nursing? Yes No

Taking oral contraceptives? Yes No

Aspirin Yes No

Penicillin Yes No

Codeine Yes No

Acrylic Yes No

Metal Yes No

Latex Yes No

Sulfa Drugs Yes No

Local Anesthetics Yes No

Other? Yes No

If Yes:

AIDS/HIV Positive

Alzheimer's Disease

Anaphylaxis

Anemia

Angina

Arthritis/Gout

Artificial Heart Valve

Artificial Joint

Asthma

Blood Disease

Blood Transfusion

Breathing Problems

Bruise Easily

Cancer

Chemotherapy

Chest Pains

Cold Sores / Fever Blisters

Congenital Heart Disorder

Convulsions

Yellow Jaundice

Cortisone Medicine

Diabetes

Drug Addiction

Easily Winded

Emphysema

Epilepsy or Seizures

Excessive Bleeding

Excessive Thirst

Fainting Spells / Dizziness

Frequent Cough

Frequent Diarrhea

Frequent Headaches

Genital Herpes

Glaucoma

HayFever

Heart Attack / Failure

Heart Murmur

Heart Pacemaker

Heart Trouble / Disease

Sleep Apnea

Hemophilia

Hepatitis A

Hepatitis B or C

Herpes

High Blood Pressure

High Cholesterol

Hives or Rash

Hypoglycemia

Irregular Heartbeat

Kidney Problems

Leukemia

Liver Disease

Low Blood Pressure

Lung Disease

Mitral Valve Prolapse

Osteoporosis

Pain In Jaw Joints

Parathyroid Disease

Psychiatric Care

Snoring

Radiation Treatments

Recent Weight Loss

Renal Dialysis

Rheumatic Fever

Rheumatism

Scarlet Fever

Shingles

Sickle Cell Disease

Sinus Trouble

Spina Bifida

Stomach / Intestinal Disease

Stroke

Swelling Of Limbs

Thyroid Disease

Tonsillitis

Tuberculosis

Tumors or Growths

Ulcers

Venereal Disease

Have you ever had any serious illnes not listed? Yes No

If Yes:

Terms I understand that the information that I have given today is correct to the best of my knowledge and that providing incorrect information can be dangerous to my (or patient's) health. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.

I authorize McLoughlin Dental Care to release my medical and/or billing information to the following individuals:

HIPAA Consent I give this practice/ clinic my consent to use or disclose my protected health information to carry out my treatment, to obtain payment from insurance companies, and for health care operations like quality reviews.
I give this practice consent to leave messages with household members and answering machines when necessary.
I have been informed that I may review the practice's "Notice of Privacy Practices" (for a more complete description of uses and disclosures) before signing this consent.
I understand that this practice has the right to change their Privacy Practices and that I may obtain any revised notices at the practice.
I understand that I have the right to request a restriction of how my protected health information is used. However, I also understand that the practice is not required to agree to the request. If the practice agrees to my requested restriction, they must follow restriction(s).
I also understand that I may revoke this consent at any time by making a request in writing, except for information already used or disclosed.

Date: 9/22/2020

16230 SE McLoughlin Blvd., Milwaukie, OR

(503) 549-4136