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Adult

_2017 Adult Registration Form – Dental

Patient Information

Gender:
Phone Type
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Spouse / Partner Information

Marital Status:
Phone Type:
Phone Type:

Emergency Contact Information

Insurance Information

Primary Insurance

Secondary Insurance

Dental History

How did you hear about our practice?
Have you ever had Orthodontic treatment (braces)?
Do you experience anxiety when you visit?
Do you snore or have you ever been diagnosed with sleep apnea?
Do your gums bleed when brushing or flossing?
Have you had a deep cleaning in the past (scaling and root planning)?
Do you like your smile?
Do you currently or have you ever had any of the following (check all that apply):

Medical History

Are you currently being treated by a physician?
Do you have any allergies/sensitivities to medications or latex?
Are you currently taking any prescription or over-the-counter medications?
Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?
Has a physician or previous dentist recommended that you premedicate before dental treatment (take antibiotics before your visit)?
(Women) Are you pregnant?
Nursing?
Taking birth control pills?
Check if you have ever had any of the following:

Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status.

I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.

If you should find it necessary to reschedule your appointment, please do so within two (2) business days to avoid a late/missed cancellation fee.

I understand that where appropriate, credit bureau reports may be obtained.



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Alan D. Belenski, D.D.S.

  • Alan D. Belenski, D.D.S. - 225 W. South Boulder Rd., Suite 200, Louisville, CO 80027 Phone: (303) 666-5080 Fax: (303) 665-4339

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