Modern Dentistry by Daniel C. Croner D.D.S.

Please fill out the following form to register with us.

PATIENT INFORMATION:

Patient Name:

E-mail:

DOB:

Address:

City:

State:

Zip:

Home Phone:

Gender:

Male

Female

Employer:

Business Phone:

Address:

City:

State:

Zip:

Please choose one:

Single

Minor

Married

Divorced

Cell phone number:

IF PATIENT IS A MINOR:
Responsible Party/Relationship to patient:

FATHER'S INFORMATION:
Name:
DOB:
Address:
City:
State:
Zip:
Home phone:
Employer:
Business Phone:
Address:
City:
State:
Zip:

MOTHER'S INFORMATION:
Name:
DOB:
Address:
City:
State:
Zip:
Home Phone:
Employer:
Business Phone:
Address:
City:
State:
Zip:

IF PATIENT IS MARRIED:
Spouse's Name:
DOB:
Address:
City:
State:
Zip:
Home Phone:
Employer:
Business Phone:
Address:
City:
State:
Zip:

MEDICAL HISTORY:

Are you in good health?

Yes

Are you under a physician's care now?

Yes

If yes, please give physician's name:

Reason for treatment:

Are you taking any kind
of medication at this time?

Yes

Please list names of medications:

Please check any conditions you presently have or have had:

Allergies	Anemia	Asthma
AIDS	Diabetes	Epilepsy
Glaucoma	Heart Trouble	Heart Murmur
Pregnant	Hepatitis A or B	Joint Replacement
Kidney or Liver Disease	Mitral Valve Prolapse	Rheumatic Fever

Have you ever had trouble
with prolonged bleeding after surgery:

Yes

Have you ever had any unusual
reactions to an anesthetic or drug?

Yes

Name of drug(s):

Is there any other information that should be known about your health?

Is there any other information that should be known about previous dental visits?

Name, address and phone number of previous dentist: