Dr. Ferris

Adult Registration Form

  • 1

    Patient Information

  • 2

    Spouse/Emergency Contact Information

  • 3

    Insurance Information

  • 4

    Dental History

  • 5

    Medical History

  • 6

    Authorization

1/6

Patient Information

Gender
MaleFemale

Phone type
HomeCell

Phone type
HomeCellOther

0%

Marital Status
SingleMarriedDivorcedWidowedSignificant Others

20%

Secondary Insurance Company

40%

How did you hear about our Practice?
AdInternetFamily or FriendPhysicianOther

Have you visited an orthodontist before?
YesNo

Have your tonsils or adenoids been removed?
YesNo

Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)?
YesNo

Do you have any missing or extra permanent teeth?
YesNo

Have you ever had an injury to (select all that apply):
TeethMouthChin

Do you have speech problems?
YesNo

Do your gums bleed?
YesNo

Do you smoke?
YesNo

Do you like your smile?
YesNo

Do you currently or have you ever had any of the following habits?
Clenching/Grinding TeethLip Sucking/BitingMouth BreathingNail bitingThumb/ Finger SuckingChewing/Eating Problems

60%

Are you currently being treated by a physician?
YesNo

Do you have any allergies/sensitivities to medications or latex?
YesNo

Are you currently taking any prescription or over-the-counter medications?
YesNo

Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of Ionimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?
YesNo

Have you had any serious illnesses or operations?
YesNo

Have you ever had a blood transfusion?
YesNo

Are you pregnant?(Women)
YesNo

Nursing?
YesNo

Taking birth control pills?
YesNo

Check if you have or have ever had any of the following:
Abnormal BleedingAnemiaArthritis, RheumatismArtificial Heart ValvesArtificial JointsAsthmaBack ProblemsBlood DiseaseBlood TransfusionCancerChemical DependencyChemotherapyCirculatory ProblemsCongenital Heart DefectCortisone TreatmentsCough, PersistentCoughing BloodDiabetesDifficulty BreathingDrug/Alcohol/AbuseEpilepsyEmphysemaFaintingFever Blisters/HerpesGlaucomaHeadachesHeart AttackHeart SurgeryHeart MurmurHeart ProblemsHemophiliaHepatitisHigh Blood PressureHigh/Low Blood SugarHIV/AIDSHospitalized for Any ReasonJaw PainKidney DiseaseLiver DiseaseMitral Valve ProlapsePacemakerPsychiatric ProblemsRadiation TreatmentRespiratory DiseaseRheumatic FeverScarlet FeverShinglesShortness of BreathSickle Cell Disease/TraitsSinus ProblemsSkin RashStrokeSwelling of Feet or AnklesThyroid ProblemsTobacco HabitTonsillitisTuberculosisUlcerVenereal Disease

80%

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

100%