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Create Smiles Dental
Philip M. Chang, DDS
1611 Crenshaw Blvd. #C, Torrance, CA 90501
Adult Online Registration
Name
Date of Birth
Current Age
Phone
Email
Sex
Male
Female
Address
City
State
ZIP
Occupation
Employer
Business Address
City
State
ZIP
Dental Insurance
Who is responsible for this account?
Relationship to Patient
Emergency Contact Name
Phone
Dental Insurance Information
Dental Insurance Primary Carrier
Insured's Name
Date of Birth
Social Security Number
Insurance Company
ID Number
Group Number
Address
Insured's Employer
Dental Insurance Secondary Carrier
Insured's Name
Date of Birth
Social Security Number
Insurance Company
ID Number
Group Number
Address
Insured's Employer
What problems would you like to discuss with the doctor and how may we help you?
Who may we thank for referring you to our office?
CHARGES AND PAYMENTS:
Charges will be explained and agreed prior to dental treatment. Payment is payable
at the time of services
are rendered. There is a
charge for broken appointments
. Failure to keep a reservation and/or failure to give the office more than a 24 hour working day notice of cancellation will constitute a broken appointment.
Thank you for your cooperation and for selecting our dental office. We will do our best to make your visits as caring as possible.
Medical History
1. When were your teeth last cleaned?
2. Are you having pain or discomfort at this time?
Yes
No
3. Do you feel very nervous about having dental treatment?
Yes
No
4. Have you ever had a bad experience in a dental office?
Yes
No
5. Have you been a patient in the hospital during the past two years?
Yes
No
6. Have you been under the care of medical doctor during the past two years for other than routine exams, and if so, why?
Yes
No
7. Are you taking any medicine or drugs? (if so, name)
Yes
No
8. Are you allergic to (i.e.., itching, rash, swelling, of hands, feet or eyes) or made sick by penicillin, aspirin, codeine,latex or any other drugs or medications? , and if so, List?
Yes
No
9. Have you ever had any excessive bleeding requiring special treatment?
Yes
No
10. Have you ever had any of the medical conditions listed below?
AIDS
Yes
No
Allergies or Hives
Yes
No
Anemia
Yes
No
Angina Pectoris
Yes
No
Arthritis
Yes
No
Artificial Heart Valve
Yes
No
Artificial Joint
Yes
No
Asthma
Yes
No
Blood Transfusion
Yes
No
Bruise Easily
Yes
No
Chemotherapy
Yes
No
Cold Sores
Yes
No
Congenital Heart Lesions
Yes
No
Cortisone Medicine
Yes
No
Cronic Cough
Yes
No
Diabetes
Yes
No
Drug Addiction
Yes
No
Emphysema
Yes
No
Epilepsy or Seizures
Yes
No
Fainting or Dizzy Spells
Yes
No
Genital Herpes
Yes
No
Glaucoma
Yes
No
Gonorrhea
Yes
No
Hay Fever
Yes
No
Heart/Bypass Surgery
Yes
No
Heart Disease/Attack
Yes
No
Heart Failure
Yes
No
Heart Murmur
Yes
No
Heart Pacemaker
Yes
No
Hepatitis A (Infectious)
Yes
No
Hepatitis B (Serum)
Yes
No
High Blood Pressure
Yes
No
HIV+
Yes
No
Hemophilia
Yes
No
Kidney Trouble
Yes
No
Liver Disease
Yes
No
Pain in Jaw Joints
Yes
No
Periodontal Disease
Yes
No
Phen-fen
Yes
No
Psychiatric Treatment
Yes
No
Rheumatic Fever
Yes
No
Rheumatism
Yes
No
Scarlet Fever
Yes
No
Sickle Cell Disease
Yes
No
Sinus Trouble
Yes
No
Stroke
Yes
No
Syphilis
Yes
No
Thyroid Disease
Yes
No
Tuberculosis (TB)
Yes
No
Ulcers
Yes
No
X-ray/Cobalt Treatment
Yes
No
Yellow Jaundice
Yes
No
Primary Physician
Physician's Name
Physician's Phone
When you walk up stairs or take a walk, do you ever have to stop because of pain in your chest, or shortness of breath, or because you are very tired?
Yes
No
Do your ankles swell during the day?
Yes
No
Has your medical doctor ever said you have cancer or a tumor?
Yes
No
Do you have any disease, condition, or problem not listed?
Yes
No
Do you smoke? If so, how much?
WOMEN: Are you pregnant now?
Yes
No
Are you taking birth control pills?
Yes
No
AUTHORIZATION AND RELEASE
Agreement 1
The above information is accurate and complete to the best of my knowledge and is only for use in treatment, billing and processing of insurance for benefits for which I am entitled. If I ever have any changes in my health, or if my medicines change, I will inform the Doctor of Dentistry at my next appointment without fail. I authorize the dentist to release any information, including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care, to third party payers and/or other health practitioners. I authorize my insurance company to pay directly to the dental office the 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.
Agreement 2
I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of his / her staff, responsible for any errors or omissions that I have made in the completion of this form.
Agreement 3
Since the office has other patients urgently seeking dental care, we strongly encourage that you keep your appointment. I understand there will be $50 broken appointment charge if I fail to give 24 hours advance notice.
Agreement 4
I consent to signing this document electronically by printing my first and last name below.
Signature of Patient
Date
Send
