Patient Registration and Health History Form

PATIENT INFORMATION (CONFIDENTIAL)

Check Appropriate Boxes

RESPONSIBLE PARTY

Is this person currently a patient in our office?

Are there other family members?

For your convenience, we offer the following methods of payment. Please check the option you prefer:

INSURANCE INFORMATION

If you have additional insurance, please complete the following:

PATIENT MEDICAL HISTORY

Although dental personnel primarily treat the area in the 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.

Are you under a physician's care now?

Have you ever been hospitalized or had a major operation?

Have you ever had a serious head or neck injury?

Are you taking any medication, pills, or prescription drugs?

Do you take, or have you taken, Phen-Fen or Redux?

Are you on a special diet?

Do you use tabacco?

Do you use controlled substances?

Women: Are you

Are you allergic to any of the following?

Do you have, or have you ever had, any of the following?

*Condition may require medication.

Have you ever had any serious illness not listed above?

SIGNATURE

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to my child or me during the period of such dental care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services.I agree to be responsible for payment of all services rendered on my behalf or my dependents. I also authorize to have photographs of my face, jaws and teeth taken. I understand that these items will be used as a record of my care, and may be used for educational purposes. I further understand that if these items are used in any publication or as a part of a demon stration, my name or other identifying information will be kept confidential. I do not expect compensation, financial or otherwise, for the use of these photographs.

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CONTACT DETAILS

586.799.4240
Frank P. Ruffino DDS
51333 Mound Road
Shelby Township, MI 48316

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