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Sedation Dentistry
Cosmetic Dentistry
Family Dentistry
Call: 301.871.8880
Fax: 301.871.0750
Email: info@doctormeltzer.com
Hours: Mon-Fri 8-5pm
Occasional Saturdays
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New Patient Registration
Please print, fill out all information and bring this form and your insurance
card on the first appointment.
You may fax it to us prior to your appointment:
301-871-0750
Name_________________________ Date of Birth____________
Today's Date ___________ S M W D
Home Address _______________________________City ________________
State ______Zip Code______
Home Phone ________________Cell Phone ________________
E-mail____________________
Employer ______________________________Occupation_______________________
Address ________________________________________________Work
Number____________________
Dental Insurance Program _________________________Local Phone
No.____________________
Insurance Group/ID Number _____________________________Social Security
#_______________
Person Responsible for Account __________Address_________________________
City _________________________________State _______________Zip
Code____________________
Referred By __________________________
Remarks______________________________________
Medical History
Physician ______________________________________Telephone___________________
Address____________________________________________________________________
Current
Medications______________________________________________________________
_____________________________________________________________________
Allergies_________________________________________________________________
_____________________________________________________________________
Are you under a physician's care now? ______If so, please give reason for
treatment__________________
Have you ever taken Fen- Phen /Redux?___________________________________
Please circle any illnesses you have ever had:
| Rheumatic fever | Diabetes | Anemia | Kidney or Liver | Other |
| Infectious hepatitis | Epilepsy | Heart Trouble | Asthma | |
| Tuberculosis | High Blood Pressure | Glaucoma | HIV Infection | |
Do you have a persistent cough or throat clearing not associated with a known
illness (lasting more than 3
weeks)?________________________________________________________________
Have you ever had trouble with prolonged bleeding after
surgery?_________________________________
Have you ever had any unusual reaction to an anesthetic or drug (like
penicillin)?_____________________
Is there any other information that should be known about your health?
____________________________
About previous dental visits?
____________________________________________________________
Signature_____________________________________________
Please Hit the "Back" Button When you are done printing.
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