REQUIRED ACCEPTANCE I understand and agree that information submitted will be sent to Dr. Harwood's office over email and this form should not be used to transmit private or sensitive information.
If you prefer, you may leave portions of this registration blank if you are uncomfortable providing the information electronically, please call our office to provide the information via phone or provide the information when you come in for your office visit.
Patient's Name (required)
Patient's Email (required)
Patient's Date of Birth (required)
Social Security Number
Patient's Home Address
City
State ---Alabama - ALAlaska - AKArizona - AZArkansas - ARCalifornia - CAColorado - COConnecticut - CTDelaware - DEFlorida - FLGeorgia - GAHawaii - HIIdaho - IDIllinois - ILIndiana - INIowa - IAKansas - KSKentucky - KYLouisiana - LAMaine - MEMaryland - MDMassachusetts - MAMichigan - MIMinnesota - MNMississippi - MSMissouri - MOMontana - MTNebraska - NENevada - NVNew Hampshire - NHNew Jersey - NJNew Mexico - NMNew York - NYNorth Carolina - NCNorth Dakota - NDOhio - OHOklahoma - OKOregon - ORPennsylvania - PARhode Island - RISouth Carolina - SCSouth Dakota - SDTennessee - TNTexas - TXUtah - UTVermont - VTVirginia - VAWashington - WAWest Virginia - WVWisconsin - WIWyoming - WY---American Samoa - ASDistrict of Columbia - DCFederated States of Micronesia - FMGuam - GUMarshall Islands - MHNorthern Mariana Islands - MPPalau - PWPuerto Rico - PRVirgin Islands - VI
Zip Code
Home Phone Number
Mobile Phone Number
How will payments be made: CheckCashVisaMastercardAmerican Express
What is your occupation?
Current Employer?
Work Phone Number
Emergency Contact's Name
Emergency Contact's Email
Emergency Contact Phone Number
Relationship to you
Physician's Name
Physician's Phone Number
Physician's Address
Who may we thank for referring you to our office?
Are you in good health?
Have you seen a physician in the last year?
Were you seen for a routine physical exam only?
Are you presently under medical care?
Have you ever been hospitalized?
Have you ever had surgery?
Have you ever had RHEUMATIC FEVER?
Have you ever been told by a physician that you have RHEUMATIC HEART DISEASE?
Have you ever been told by a physician that you have a HEART MURMUR?
Have you ever been told by a doctor that you need a premedicate before dental treatment?
Have you ever had HEPATITIS or JAUNDICE (yellow skin or eyes)?
Have you ever been told that you have LIVER DISEASE?
Have you ever had EPILEPSY or SEIZURES?
Do you urinate often or wake up in the night to urinate?
Have you ever had DIABETES?
Have you ever had KIDNEY TROUBLE?
Have you ever had HIGH BLOOD PRESSURE?
Do you have chest pain or exertion?
Have you ever had HEART TROUBLE or a HEART ATTACK?
Do you have a PACE MAKER?
Have you ever had a PROSTHETIC HEART VALVE REPLACEMENT?
Have you ever had VENEREAL DISEASE?
Have you ever had THYROID DISEASE?
Have you ever had TUBERCULOSIS?
Have you ever had PROLONGED BLEEDING?
Have you ever had a BLOOD DISEASE or DISORDER?
Have you ever had PAINFUL or SWOLLEN JOINTS?
Do you have any PROSTHETIC REPLACEMENTS?
Have you ever had a TUMOR or GROWTH?
Do you have ASTHMA?
Do you have or have you ever been exposed to HIV/AIDS?
Have you ever had a problem from the administration of local anesthetic?
Have you ever had an ALLERGIC response to any antibiotic? If yes, please list:
Have you ever had an ALLERGIC response to any other medication? If yes, please list:
Have you ever been treated for CHRONIC TENSION or MIGRAINES?
Do you clench, grind or brux your teeth?
Have you ever been treated for ULCERS or NERVOUSNESS?
Do you have a history of chronic DIZZINESS or FAINTING?
Have you ever been told that you are ANEMIC?
Do you have recurrent or chronic SINUS problems?
Have you lost weight without dieting in the past few months?
Are you now or have you in the past six months been treated with steroids?
Are chills and/or night sweats common?
Do you have any unexplained swelling or tenderness in your lymph glands?
Do you have chronic DIARRHEA?
Do you often feel tired and/or confused?
Is there anything about your medical history that has not been covered, that you feel is important for us to know?
If yes, please describe here:
If any, what medications are you currently taking?
WOMEN: Are you pregnant?
Are you enrolled in a DENTAL PLAN?
Plan Name (required)
Plan Identification Number (required)
I, the undersigned, consent to receive this consultation and should I agree to accept professional advice, also consent to the performing of whatever procedure may be decided upon to be necessary or advisable in the opinion of the doctors.
I also understand that only the root canal treatment is to be performed in this office. The permanent (outside) restoration (filling, inlay, crown, etc.) will be done by my regular dentist.
I also acknowledge full responsibility for the payment of such services. Unless other arrangements are made in advance, payment is expected as service is rendered.
TYPE FULL NAME AS YOUR DIGITAL SIGNATURE (required)
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