• WELCOME! AMADOR FAMILY DENTISTRY, PLLC

    Patient Registration & Health Record (front & back)

     In order to render the proper dental services, to you, would you please be kind enough to answer the following questions.  Thank you for your cooperation.

  • Date Format: MM slash DD slash YYYY
  • Home Address
  • City
  • State
  • ZIP Code
  • Homephone
  • Workphone
  • Cellphone
  • Email address
  • Referred by
  • Social security #
  • Date Format: MM slash DD slash YYYY
    Date of birth
  • Marital Status
  • Sex
  • Employer Name
  • Employer Address
  • Employer City
  • Employer State
  • Employer ZIP Code
  • Person To Notify In Emergency
  • Phone #
  • Alternate #
  • Homephone
  • Workphone
  • Social security #
  • Date Format: MM slash DD slash YYYY
    Date of birth
  • Marital status
  • Sex
  • Employer name
  • Employer address
  • Employer state
  • Employer ZIP Code
  • Employer name or Plan name
  • Group #
  • Insurance company name
  • Phone #
  • Claim address
  • City
  • State
  • ZIP Code
  • Subscriber's name
  • Date Format: MM slash DD slash YYYY
    Date of birth
  • ID #
  • Relationship to patient
  • Name and address of your primary care physician
  • Have you ever been treated for or do you currently have :

     

  • Medical review (for the doctor’s use only)

     

  • Dental History

     

  • Date Format: MM slash DD slash YYYY
  • By signing this questionnaire, i certify that i have answered every question and filled in every blank. i further certify that i have asked for assistance in answering every question i was unsure about or did not understand. to the best of my knowledge, the answers to these questions are complete and accurate. in addition, i agree to inform the dentist whenever there is a change in my health status.

    I authorize the dentist to release health information about me and information about my dental treatment to other health professionals and to insurance companies. i understand that responsibility for payment for dental services provided in this office for myself or my dependents is mine, due and payable in full at the time of service unless prior financial arrangements have been approved by the dentist. i further understand that should my account have to be referred to an attorney for collection, i am responsible for all fees and costs incurred therein. a one and one half percent per month service charge will be imposed on account balances due over thirty days. i also authorize any insurance payments may be sent to the attending dentist.

     

  • Person completing this form:
  • Date Format: MM slash DD slash YYYY
  • If this form was not completed by the patient, please provide the following information: