THE DENTISTS AT GRAND PARKWAY
PATIENT REGISTRATION FORM

How did you hear of our office? ________________________________________________________

Patient Information

First Name ________________ Middle______Last Name_____________________Nickname___________

Home#____________________Work#__________________________Cell#_______________________

Circle one: Male Female Circle one: Single Married Divorced Separated Widowed

Birth Date______________ Social Security_____________________ Drivers License__________________

Address___________________________________________ City, ST, Zip_________________________

Email___________________________________________ Would you like correspondence by email: Y N

Emergency Contact Name______________________________________ Phone_____________________

Student Status: ___Full Time ___Part Time School_______________________________________

Do you have a preferred dentist?_________________________ Hygienist?_________________________

Responsible Party (if someone other than patient) ___Responsible Party is also Policy Holder for Patient

First Name _________________________ Middle________Last Name_____________________________

Address___________________________________________ City, ST, Zip_________________________

Home#____________________Work#__________________________Cell#_______________________

Birth Date______________ Social Security_____________________ Drivers License__________________

Dental Insurance Information

Name of Insured____________________________ Relationship to Patient: Self Spouse Child Other

Birth Date________________________________ Insurance Co________________________________

Social Security_____________________________ Ins. Phone #_________________________________

ID#_____________________________________ Group #____________________________________

Employer_________________________________ Address____________________________________

Address___________________________________ City, ST, Zip_________________________________

1. The undersigned has authorized the doctor and/or hygienist to take x-rays, study models, photographs, or any other
diagnostic aids appropriate to make a thorough diagnosis of the patient's dental needs.
2. I authorize the doctor to perform all recommended treatment mutually agreed upon and to use the appropriate
medication and therapy indicated for treatment in connection with patient.
3. I understand that all responsibility for payment of dental services provided in this office is mine, due and payable at
the time services are rendered, unless other arrangements have been made. In the event payments are not received
by the agreed upon date. I understand that a 1.5% finance charge (18% APR) will be added to my account.
4. Insurance is billed as a courtesy to our patients. I also understand the expected insurance payment is only an
estimate and not a guarantee of payment. I agree to be responsible for services render in the even my insurance
company denies payment for any portion. Any unpaid insurance balance, after 90 days, becomes the patient's
responsibility. This balance must be paid by the patient.
5. I authorize the insurance proceeds for treatment to be paid directly to the doctor.
6. I have been advised and acknowledge the office's Notice of Privacy Practices. I may request a copy at any time.
7. I authorize this office to conduct business in a customary matter: reminder calls, confirmation of insurance, etc.
8. I understand there will be a $50.00 broken appointment charge if I do not give 24-48 hours cancellation notice.

__________________________________________________________________________________
Signature of Patient, Parent, or Guardian Date

THE DENTISTS AT GRAND PARKWAY
MEDICAL HISTORY FORM

Patient's Name________________________________________________________________

Although dental personnel primarily treat the area in and around your mouth, your mouth is part of your entire
body. Health problems that you may have, or medication that you may be taking, could have an important
interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Do you have any artificial joints, pins, augmentation or implants of any kind?	Y	N	If Yes, Please List:___________________________
Are you under a physician's care now?	Y	N	If Yes, Please List:___________________________
Have you been hospitalized or had a major operation?	Y	N	If Yes, Please List:___________________________
Have you ever had a serious head or neck injury?	Y	N	If Yes, Please List:___________________________
Are you taking any medications, pills or drugs?	Y	N	If Yes, Please List:___________________________
Have you taken Phen-Fen or Redux?	Y	N	If Yes, Please List:___________________________
Are you on a special diet?	Y	N	If Yes, Please List:___________________________
Do you use tobacco?	Y	N	If Yes, Please List:___________________________
Do you use controlled substances?	Y	N	If Yes, Please List:___________________________

Women: Are you: Pregnant/Trying to get pregnant?___ Nursing?___ Taking oral contraceptives?___

Are you allergic to any of the following? If no, please check ___

___Aspirin ___Penicillin ___Codeine ___Acrylic ___Metal ___Latex ___Local Anesthetic ___Sulfa

___Other______________________________________________________________________

Do you have, or have you had, any of the following? If none apply, please check___

__AIDS/HIV Positive	__Chest Pains	__Frequent Headaches	__Irregular Heartbeat	__Scarlet Fever
__Alzheimer's Disease	__Cold Sores/Fever Blisters	__Genital Herpes	__Kidney Problems	__Shingles
__Anaphylaxis	__Congenital Heart Disorder	__Glaucoma	__Leukemia	__Sickle Cell Disease
__Anemia	__Convulsions	__Hay Fever	__Liver Disease	__Sinus Trouble
__Angina	__Cortisone Medicine	__Heart Attack/Failure	__Low Blood Pressure	__Spina Bifida
__Arthritis/Gout	__Diabetes	__Heart Murmur*	__Lung Disease	__Stomach/Intestinal Disease
__Artificial Heart Valve*	__Drug Addiction	__Heart Pace Maker*	__Mitral Valve Prolapse*	__Stroke
__Artificial Joint*	__Easily Winded	__Heart Trouble/Disease	__Pain the Jaw Joints	__Swelling of Limbs
__Asthma	__Emphysema	__Hemophilia	__Parathyroid Disease	__Thyroid Disease
__Blood Disease	__Epilepsy or Seizures	__Hepatitis A	__Psychiatric Care	__Tonsillitis
__Blood Transfusion	__Excessive Bleeding	__Hepatitis B or C	__Radiation Treatments	__Tuberculosis
__Breathing Problems	__Excessive Thirst	__Herpes	__Recent Weight Loss	__Tumors or Growths
__Bruise Easily	__Fainting Spells/Dizziness	__High Blood Pressure	__Renal Dialysis	__Ulcers
__Cancer	__Frequent Cough	__Hives or Rash	__Rheumatic Fever*	__Venereal Disease
__Chemotherapy	__Frequent Diarrhea	__Hypoglycemia	__Rheumatism	__Yellow Jaundice

*Condition may require medication

Have you ever had any serious illiness not listed above? Yes No__________________________________

Additions comments you would like to share:____________________________________________________

____________________________________________________________________________________

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing
incorrect information can be dangerouse to my (or patient's) health. It is my responsibility to inform the dental
office of any changes in medical status.

__________________________________________________________________________________
Signature of Patient, Parent, or Guardian Date