Mcmillendental.com

McMillen Dental Group
Patient Registration and Health History
PLEASE COMPLETE THE FOLLOWING CONFIDENTIAL INFORMATION If This Appointment is for you, Fill in the info below Date: ____________________________________ Name: _____________________________________ Spouse: ___________________________________ Address: ________________________________________________________________ City: ______________________________________ State: __________________ Zip: ______________ Home Phone # ___________________________ Dr. License # _________________________________ Birthdate: ___________________ Age: ___________ SSN: ___________________________________ Married: ________ Single: ________ Divorced: ________ Widowed: ________ If This Appointment is for your child (Under the age of 18) , Fill in the info below Date: ____________________________________
Name: ____________________________________ Spouse: ___________________________________
Address: __________________________________________________________________
City: _____________________________________ State: ___________________ Zip: _____________
Home Phone # ___________________________
Birthdate: ___________________ Age: ___________ Grade: ________
PRIMARY: McMillen Dental will submit ins. forms up to 2 times for same service.

E After that, it’s the patient’s responsibility to contact carrier for pmt.

Insurance Co. ________________________________________Phone # __________________________
Employer _____________________________
Insurance Address _______________________
Employee Birthdate _______________________ _______________________ Employee SSN ___________________________ Insurance Co. _________________________________________Phone # __________________________ Employer _______________________________ Insurance Address ________________________ Employee Birthdate _______________________ ________________________ Employee SSN ___________________________ Is another member of your family or relative a NO If yes, what month? ________ Are you taking birth control pills? 1. Are you having pain or discomfort at this time? 2. Have you been a patient in the hospital during the last two years? 3. Have you been under the care of a medical doctor during the past two years? Physician’s Name __________________________________________________________________________ Address ___________________________________________________ Ph # __________________________ 4. Have you taken any medicine or drugs during the past two year? Are you now taking any medication, drugs, or pills? If yes, please list ______________________________________________________________________________________ 5. Are you allergic or have you reacted adversely to any of the following medications? 6. Are you avare of being allergic to any other medication or substance? If yes, please list ______________________________________________________________________________________ 7. Check the box of the following which you have had or have at present. Any Heart Problem
7a. To Complete your medical history, are there any other conditions the Dr. Should know of?
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
8. When you walk up stairs or take a walk, do you ever have to stop because of pain in your chest, shortness of breath or because you
9. Do you use more than 2 pillows to sleep? 10. Do you ever wake up from sleep short of breath? 11. Has your medical doctor ever said you have a cancer or tumor? 12. Do you have any disease, condition, or problem not listed? 13. Do you smoke and how much? __________________________ INSURANCE:- I understand that the portion of my treatment not covered by insurance is due and payable at each visit.
I also understand that my dental insurance is a contract between me and the insurance carrier, and not

between the insurance carrier and the dentist, and I am responsible for all dental fees. If my insurance
company has not paid their portion within 60 days of being billed, I understand that the balance will
become due and payable from me.
MISSED APPOINTMENTS – A missed appointment is a loss to everyone. I understand that I may be charged a small fee for broken

appointments with less than 24 hrs. notice.

CONSENT: The undersigned hereby authorizes Doctor to take X-rays, study models, photographs, or any other diagnostic aids deemed
appropriate by Doctor to make a thorough diagnosis of the patient’s dental needs. I also authorize Doctor to perform any and all forms of
treatment, medication, and therapy that may be indicated in connection with (Name of Patient) _______________________________________
and further authorize and consent that Doctor choose and employ such assistance as he deems fit. I also understand the use of anesthetic agents
embodies a certain risk. I understand that responsibility for payment for Dental Services provided in this office for myself or my dependents is
mine, due and payable at the time services are rendered unless financial arrangements have been made. I further understand that a 1-1/2% finance
charge (18% annually) will be added to any balance over 60 days. In the event of default I (we) promise to pay legal interest on the indebtedness,
together with such collection costs and reasonable attorney fees as may be required to effect collection of this note. I also assign all insurance
benefits to the Doctor. I also understand that it is my responsibility to notify the doctor of any changes in my health or address history.
The person who brings the minor is financially responsible.
Patient or guardian of minor __________________________________________________________ Date _____________________________
Date________________________________________________ Date ______________________________________________________
Signature ____________________________________________ Signature __________________________________________________
Date ________________________________________________ Date ______________________________________________________
Signature ____________________________________________ Signature __________________________________________________

Source: http://www.mcmillendental.com/docs/New-Patient-Forms.pdf