REGISTRATION FORM

Please complete this form and submit it to our office.

Also please print yourself a copy of your completed form and bring it to our office

with you at your first appointment.

Whom may we thank for this referral?

Yellow Pages

Newspaper

Our Sign

Direct Mail

Another Patient
Another Doctor
Other

Have any of your family members been patients of Dr. Patrick A. Palma?Yes No

Name of Spouse: Birth Date:// SS#:

Occupation: Employer:

Responsible Party (If patient is a minor):
Relationship

Address: SS#:

Home Phone: Business Phone:

Name of Relative NOT Living With You:
Relationship

Address: Daytime Phone:

Whom to contact in case of an emergency:
Daytime Phone:

RELEASE

I authorize the doctor to perform diagnostic procedures and treatment as may be necessary for proper care.
I understand that I am responsible for all costs of dental treatment and, if required, all costs of collection.

Patient / Parent / Guardian Signature: Date: //

MEDICAL HISTORY
A Comprehensive Medical and Dental History is Required for an Accurate Diagnosis and the Safe and Effective Treatment.

Name:

DO YOU HAVE OR HAVE YOU EVER HAD:

1. Hospitalization for illness or injury?	YesNo	34. Chest pains on mild exertion	YesNo
Had an allergic reaction to . . .		35. Hives, skin rash, hay fever	YesNo
-------- Aspirin	YesNo	36. Asthma	YesNo
--------- Penicillin, Keflex, Amoxicillian	YesNo	37. Emotional problems or tension	YesNo
-------- Erythromycin	YesNo	38. A tumor or abnormal growth	YesNo
-------- Tetracycline	YesNo
------- Codeine, Vicodin, Percodan	YesNo
------- Sedatives or sleeping pills	YesNo	Are You:
------- Narcotics, Demerol, Morphine	YesNo	39. Presently being treated for any illness	YesNo
-------- Tranquilizers, Valium	YesNo	Presently being treated for depression	YesNo
------- Dental Anesthetics, Novocaine	YesNo	Taking any medications regularly	YesNo
11. Have You Ever Had Hepatitis	YesNo	40. Often exhausted, fatigued or thirsty	YesNo
12. Jaundice (yellow skin and eyes)	YesNo	41. AIDS or HIV positive	YesNo
13. Epilepsy	YesNo	Confidential information for treatment only
14. Arthritis	YesNo	42. Subject to frequent headaches	YesNo
15. Venereal disease	YesNo	43. Do you smoke or use tobacco	YesNo
16. Rheumatic Fever	YesNo	44. Drug or chemical dependency	YesNo
17. Scarlet fever	YesNo	45. Recent weight changes	YesNo
18. Anemia or other blood disorders	YesNo	46. Urinating more than 6 times a day	YesNo
19. Prolonged bleeding	YesNo
20. Kidney disease	YesNo
21. Diabetes	YesNo
22. Cancer	YesNo
23. Liver disease	YesNo
24. Tuberculosis	YesNo
25. Emphysema	YesNo
26. Thyroid or parathyroid disorders	YesNo
27. Heart murmur/Heart trouble	YesNo
28. Arteriosclerosis	YesNo
29. High blood pressure	YesNo	If Female, Are You Now:
30. Low blood pressure	YesNo	47. Pregnant or possibly pregnant	YesNo
31. Artificial joints or prostheses	YesNo	48. Taking birth control pills	YesNo
32. Stroke	YesNo
33. Radiation treatment	YesNo

Please Fully Explain any 'Yes' Answers, And List All Medications That You Are Currently Taking

Patient / Parent / Guardian Signature:
Doctor Signature Date: //

DENTAL HISTORY
Getting To Know You Better

DO YOU HAVE OR HAVE YOU EVER HAD:

1. Bleeding Gums	YesNo	14. Notice your bite change	YesNo
2. Tender or sore gums	YesNo	15. Head or neck injuries	YesNo
3. Loose teeth	YesNo	16. Instructions in proper oral hygiene	YesNo
4. Gum absess / boils	YesNo	17. Periodontal or gum treatment	YesNo
5. Periodontal disease(pyorrhea)/gum disease	YesNo	18. Orthodontic treatment (tooth straightening)	YesNo
6. Gum recession	YesNo	19. Root canal treatment (nerve removed)	YesNo
7. Teeth sensitive to hot, cold, sweets	YesNo	20. Teeth ground or bite adjusted	YesNo
8. Bad taste or odor in your mouth	YesNo	21. Oral surgery / tooth extraction	YesNo
9. Grinding or clenching teeth	YesNo	22. Fever blisters on your lips or mouth	YesNo
10. Sore jaws	YesNo	23. Anxiety of dental treatment	YesNo
11. Jaw clicking or popping	YesNo	24. Excessive bleeding after dental extraction	YesNo
12. Difficulty chewing	YesNo	25. Reaction to "Novocain"/local anesthetic	YesNo
13. Trouble opening / closing mouth	YesNo	26. Other (Please Explain)	YesNo

Previous Dentist:
City:
How Long Ago Was Your Last Dental Visit?
How Often Do You See Your Dentist?

Do You Have ' Dental Insurance ' ?
If So, The Name Of The Insurance ...
The Phone Number Of The Insurance Company.....
What concerns you most about your treatment?

Please make any additional comments that you feel would help us understand
your concerns and treat you as you would prefer to be treated.