Registration Information

Two convenient ways to register. Online submission or download and fill out before you come.

Online Registration

Patient's Name:
Date of Birth:
Social Security Number:
Name of Spouse
Social Security Number of Spouse
If Child, Parent Name

Check if applicable:	Single Married Widowed Divorced Separated


Mailing Address:
City:
State:
Zip:
Phone Number:
Cell Phone Number:


Patient 's Employer:
Business Phone:
Business Address:
City:
State:
Zip:
Current Position:
How Long Held:


Spouse's Employer:
Business Phone:
Business Address:
City:
State:
Zip:
Current Position:
How Long Held:


Purpose of this Appointment:


In case of Emergency Contact:
Relation to Patient:
Phone:
Mailing Address:
City:
State:
Zip:
Phone Number:


Who will pay this account:
Relation to Patient:


Do you have insurance that may cover ant part of our professional services?	Yes No
Name of Company:
Group Number:
Policy Number:
Name of Insurance Card Holder:
Social Security Number:
Date of Birth:


Whom may we thank for referring you?:
Comments:


Briefly Describe Your Problem:
How long have you had this problem?:


Pain:	Never (If checked, go to Swelling) In the Past Today


Location:	Upper Left Upper Right Upper Front Lower Left Lower Right Lower Front


Duration:	Seconds Minutes Hours Constant


Quality:	Dull Pain Throbbing Pain Sharp Pain


Pain Scale ( 1 being mild, 10 being severe):


Provoked By:	Cold Hot Biting Sweet Spontaneous (unprovoked) Other


Swelling:	In the Past Today None


Anxiety Level


Physician's Name:
City:
Date of Last Visit:


Have you ever taken any of the group of drugs referred to as "fen-phen?"	Yes No
Have you ever taken any drugs referred to as "bisphosphonates?" (fosmax, actonel, aredia, zometa)	Yes No
Have you been hospitalized or had a serious illness within the past 5 years?	Yes No


Do you require pre medication with antibiotics for any of the following reasons?	Artificial Joints Heart Rheumatic Fever Phen/Fen


Do you have or have you ever had any of the following conditions? Please check:	AIDS/HIV Anemia type: Alzheimer's disease Arthritis, Rheumatism Artificial Heart Valve year: Artificial Joints year: Asthma Back / Neck Problems Bleeding Abnormality Blood Thinners Cancer Chemical Dependency Chemotherapy Congenital Heart Condition Diabetes type: Ear (Cochlear) Implant Emphysema Epilepsy or Seizures Glaucoma Heart Murmur Heart Disease / Heart Surgery Hepatitis type: High Blood Pressure Kidney Disease Liver Disease Pacemaker Psychiatric Care Radiation Treatment Respiratory / Breathing Problems Rheumatic Fever Sinus Trouble Steroid Treatment Stroke TMJ Disorder Tuberculosis Tumor or Growth Ulcer Venereal Disease Other:


Are you Pregnant?	Yes Due Date:
Are you Nursing	Yes No
Are you taking Birth Control Pills?	Yes No


List any Medications you are currently taking and the correlating diagnosis:


Allergies:	Aspirin or NSAIDs Codeine Local Anesthetic Sulfa drugs Latex Iodine Penicillin (or other antibiotics) Other:


Comments:

Download Registration Form

You may register with our office by completing our online Patient Registration Form. Please print this form, fill it out, and fax it to:
(760) 346-0040.