Patient Registration
Patient Information:
Name
Birthdate
Social Security #
Address
City
Zip
Home Phone
Gender:- MaleFemale
Marital Status: Single Married Divorced Widowed
Employer
Occupation
Work Phone
Cell Phone
Email
Spouse
Birthdate
Social Security #
Employer
Occupation
Work Phone
Cell Phone
Email
If patient is minor, please complete the following
Name of person responsible for this account
Relationship to patient
Address
City
Zip
Home Phone
Birthdate
Social Security #
Employer
Occupation
Work Phone
General Information:
Who may we thank for referring you?
Previous Dentist Name
Phone
Patient's Physician
Address
Phone
Emergency Contact
Address
Phone
Insurance Information:
Primary Coverage:
Insurance Company
Claim Address
Policy Holder
Birthdate
Social Security #
Employer
Group #
Secondary Coverage:
Insurance Company
Claim Address
Policy Holder
Birthdate
Social Security #
Employer
Group #
We would like to introduce you to our Smile Reminder Program
Smile Reminder ™ Is a way that we can make it easier for you to remember your appointment by sending you reminders via text messages to your cell phone, pager, e-mail or PDA. It's benefits include being able to read the message at your time is valuable and It's sometimes challenging to recieve our calls.

If this is not something you are interested in please let is know and we will send your confirmations via mail.
Smile Reminder-
Patient Contact Information
Name:
Cell:
Email:
Pager:
Medical History and Questionnaire
Do you have, or have you had,any of the following? Please check that all apply.
None of below
Congestive Heart Failure
Shortness of Breath
Blood Pressure Problem
High Low
Heart Murmur
Rheumatic fever
Pacemaker
Artificial heart valve/type
Premed required/type
Yes No
Premed with:
Easy brusing/abnormal bleeding (circle one)
Frequent Nose bleeds
Blood disease(anemia)
Blood transfusion
Blood thinner/Daily asprin
History of stroke or TIA(circle one)
Seasonal allergies
Sinus problem
Asthma
Tuberculosis, COPD
Hepatitis, type:
Liver problem
Ulcers
Kidney problems
Bladder problems
Gallstones/gallblader problem
Kidney or bladder problems
Osteoporosis or osteopenia
Arthritis
Back/Neck Pain
Joint Replacement
Type:
Premed required/type:
Do you take or have you taken any of these medications?
Etidronate(Didronel)
Tiludronate(Skelid)
Neridronate
Alendronate(Fosamax)
Ibandronate(Bondronate/Boniva)
Risendronate(Actonel)
Zolendronate(Zometa)
Clodronate(bonefos, Loron)
Pamidronate(Aredia)
Olpadronate
Fainting Spells, Seizures, or Epilepsy
History of head trauma
Frequent/severe headaches/migranes
Do you take antidepressants?
Yes
Thyroid Concerns
Diabetes/Type
Date of most recent hA1c
Urinate more than 6 times per day
Thirst/dry mouth
Family History of Diabetes
Do you smoke/how much?
How Much?:
Do you use smokeless tobacco/how much?
How Much?:
Herpes/other STD
HIV+/Aids
History of alcohol abuse
Are you an organ donor/recipient?
Yes
Other Disease not listed
List of all meds you take and for what
List all allergies/symptoms
Women
Pregnant/Due Date
Are you Nursing?
Yes
Contraceptives/other hormones
Men
Do you take medications for erectile dysfunction
Yes
No
Do you have a history of prostate cancer?
Yes
No
Other Comments
Is there anything else you like to discuss with us
Dental History and Questionnaire
What is your estimation of your dental health? Excellent Good Fair Poor
Is your mouth comfortable now? Yes No
If no, please describe the discomfort or problem:
Do you have any active dental disease in your mouth that you are aware of? Yes No
How long have you been with your present general dentist?
How much dentistry has been performed on your mouth this year?
Do any members of your family presently have or have they had in the past
Dentures
Periodontal Disease
Are you satisfied with the appearance of your teeth mean to you? Yes No
What would the loss of your natural teeth mean to you?
What are your goals and expectations of periodontal therapy?
Have you had any serious trouble associated with a previous dental experience? Please specify
Please list any other comments regarding your teeth ,mouth, or dental history

I authorize the release of my dental records from Drs. Culberson, Mulliken or Rutherford to individuals involved in my dental care. I further authorize the release of records from any individuals to Drs. Culberson, Mulliken or Rutherford,

I authorize insurance payments to be made directly to Drs. Culberson, Mulliken or Rutherford. I understand that Iam responsible for any unpaid balance.

I am aware that should I not provide adequate notice to change an appointment, I may be charged a fee. (7 business days for a surgical appointment and 2 business days for a cleaning appointment).

I am aware of and have received notice of the Health Insurance Portability and Accountability Act (HIPAA).

NOTICE OF PRIVACY PRACTICES—ACKNOWLEDGEMENT

We keep a record of the health care services we provide for you. You may ask to see and copy that record. You may also ask to correct that record. We will not disclose your record to others unless you direct us to do so or unless the law authorizes or compels us to do so. You may see your record or get more information about it by contacting us.

Our Notice of Privacy Practices describes in more detail how your health information may be used and disclosed, and how you may access your information.

By my signature below I acknowledge receipt of the Notice of Privacy Practices.

AUTHORIZATION FOR APPOINTMENT CONFIRMATION

As a courtesy to our patients, we often will give a variety of appointment reminders. Some of these reminders may generally include, but are not limited to, appointment post-cards sent through the mail, messages left with roommates/family members, and voicemail messages. Usually within these reminders a certain amount of specific and detailed information, consisting of the patient's appointment time and date, or need for an appointment may be included.

By my signature below, I authorize the offices of Drs. Culberson, Mulliken or Rutherford and their staff to confirm my appointments and remind me of the need for an appointment in the above-mentioned ways, for the duration of my treatment with their office.

Patient's Signature
Date
Parent or Guardian (If Patient is a Minor)
Date
This form will be retained in your dental record.
Patient Information
Have you ever been told you occasionally snore?
Yes No
Has anyone ever witnessed that you stop breathing while sleeping and/or snoring?
Yes No
Have you ever been diagnosed with sleep apnea?
Yes No

Please check the appropriate box below:

High Blood Pressure
Yes No
Heart Disease
Yes No
History of Heart Attack or Stroke
Yes No
Mood Disorder
Yes No
Impaired Thinking
Yes No
Insomnia
Yes No

Epworth Sleepiness Scale

Please rate the chances of you dozing off in the following situations on a scale of 0-3:

Situation

Sitting & reading
Watching TV
Sitting inactive in a public place
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting & talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in traffic

Chance of Dozing

0 = no chance of dozing

1 = slight chance of dozing

2 = moderate chance of dozing

3 = high chance of dozing

Have you ever tried any of the following to help improve your sleep breathing?

CPAP
Yes No
Weight Loss
Yes No
Nose Strips
Yes No
Side Sleeping
Yes No
Surgical Treatments
Yes No
Patient's Signature
Date

Patient Information Form

   I authorize the offices of Drs. Culberson, Mulliken or Rutherford and their staff to confirm my appointments and remind me of the need for an appointment in the mentioned way, for the duration of my treatment with their office
Dear Mill Creek Dentistry
  • at your earliest convenience.