Patient Forms

New Patient Registration Form

Please fill out our New Patient Form before your first visit. If you have questions, please call Fujioka Family Dentistry at 360-696-4439.

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Welcome to Fujioka Family Dentistry!

required field — please fill out all required fields.

This form contains sensitive personal and health information. Submission details are not included in notification emails.

ABOUT YOU

Name:

FirstMiddleLast

What you prefer to be called:

Gender:

Male Female

Birthdate:Age:SSN:

Mailing Address:

Street AddressAddress Line 2CityState / ProvinceZIP / Postal Code

Home Phone #:Work Phone #:Cell phone #:Email address:Referred by:Employer:How long?Occupation:

Employer address:

Street AddressCityState / ProvinceZIP / Postal Code

Spouse's name:

INSURANCE INFO

Primary Insurance

Company name:Company phone#:

Company address:

Street AddressCityState / ProvinceZIP / Postal Code

Insured's ID:Group # (Plan, Local or Policy #):Insured's name:Insured's employer:Relation:Birthdate:

Secondary Insurance

Company name:Company phone#:

Company address:

Street AddressCityState / ProvinceZIP / Postal Code

Insured's ID:Group # (Plan, Local or Policy #):Insured's name:Insured's employer:Relation:Birthdate:

ACCOUNT INFO

Person ultimately responsible for the account

Name:

FirstLast

Relation:

Billing address:

Street AddressCityState / ProvinceZIP / Postal Code

SSN:Drivers license #:Work phone #:Initials:

I hereby authorize assignment of my insurance rights and benefits directly to the provider for services rendered. I fully understand I am solely responsible for any balance not paid by my insurance company (if offered at this office).

IN THE EVENT OF AN EMERGENCY

Whom should we contact?Relation:Primary phone #:Alternate phone #:Who is your medical doctor?Medical doctor's phone #:

DENTAL INFORMATION

Reason for the appointment:

Exam Emergency Consultation

Are you in pain?

Yes No

How long?Other:

Do you require pre-medication?

No Yes Don't know

Previous dentist name:Phone #:Last dental exam:Last dental x-rays:Times a day you brush:Times a day you floss:

What types of toothbrush bristles do you use?

Soft Medium Hard

MEDICAL HISTORY

Are you under a physician's care now?

Yes No

If yes, please explain:

Have you ever been hospitalized or had a major operation?

Yes No

If yes, please explain:

Have you ever had a serious head or neck injury?

Yes No

If yes, please explain:

Are you taking any medications, pills or drugs?

Yes No

If yes, please explain:

Do you take, or have you taken, Phen-Fen or Redux?

Yes No

If yes, please explain:

Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?

Yes No

If yes, please explain:

Do you use tobacco?

Yes No

If yes, please explain:

Do you use controlled substances?

Yes No

If yes, please explain:

Do you use marijuana?

Yes No

If yes, please explain:

WOMEN:

Are you Pregnant/Trying to get pregnant?

Yes No

Taking Oral Contraceptives?

Yes No

Nursing?

Yes No

Do you take herbal supplements or other OTC products ex: fish oil or vitamins?

Yes No

If yes, please list:If yes, please explain:Are you allergic to anything not listed? Please specify.

Do you have, or have you had, any of the following?

AIDS/HIV Positive

Yes No

Alzheimer's Disease

Yes No

Anaphylaxis

Yes No

Anemia

Yes No

Angina

Yes No

Anxiety

Yes No

Arthritis / Gout

Yes No

Artificial Heart Valve

Yes No

Artificial Joint

Yes No

Asthma

Yes No

Blood Disease

Yes No

Blood Transfusion

Yes No

Breathing Problem

Yes No

Bruise Easily

Yes No

Cancer

Yes No

Chemotherapy

Yes No

Chest Pains

Yes No

Cold Sores / Fever Blisters

Yes No

Congenital Heart Disorder

Yes No

Cortisone Medicine

Yes No

Depression

Yes No

Diabetes

Yes No

Drug Addiction

Yes No

Emphysema

Yes No

Epilepsy or Seizures

Yes No

Excessive Bleeding

Yes No

Excessive Thirst

Yes No

Fainting Spells / Dizziness

Yes No

Frequent Cough

Yes No

Frequent Headaches

Yes No

Dementia

Yes No

Glaucoma

Yes No

Hay Fever

Yes No

Heart Attack / Failure

Yes No

Heart Murmur

Yes No

Heart Pacemaker

Yes No

Heart Trouble / Disease

Yes No

Hemophilia

Yes No

Hepetitis A

Yes No

Hepetitis B or C

Yes No

Herpes

Yes No

High Blood Pressure

Yes No

High Cholesterol

Yes No

Hives or Rash

Yes No

Hypoglycemia

Yes No

Irregular Heartbeat

Yes No

Kidney Problems

Yes No

Leukemia

Yes No

Liver Disease

Yes No

Low Blood Pressure

Yes No

Lung Disease

Yes No

Mitral Valve Prolapse

Yes No

Osteoporosis

Yes No

Pain in Jaw Joints

Yes No

Parathyroid Disease

Yes No

Parkinson's Disease

Yes No

Psychiatric Care

Yes No

Radiation Treatments

Yes No

Renal Dialysis

Yes No

Rheumatic Fever

Yes No

Rheumatism

Yes No

Scarlet Fever

Yes No

Shingles

Yes No

Sickle Cell Disease

Yes No

Sinus Trouble

Yes No

Spina Bifida

Yes No

Stomach / Intestinal Disease

Yes No

Stroke

Yes No

Thyroid Disease

Yes No

Tonsillitis

Yes No

Tuberculosis

Yes No

Tumors or Growths

Yes No

Ulcers

Yes No

Venereal Disease

Yes No

Have you ever had any serious illness not listed above?

Yes No

Comments:

Acknowledgements | Please check the required boxes:

Our policy requires payment in full for all services rendered at the time of visit, unless other arrangements have been made with the business manager. If account is not paid within 90 days of the date of service and no financial arrangements have been made, you will be responsible for legal fees, collection agency fees, interest charges and any other expenses incurred in collecting your account.

I authorize the staff to perform any necessary services needed during diagnosis and treatment. I also authorize the provider to release any information required to process insurance claims.

I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes to the information I have provided.

I understand that if I am not able to keep an appointment I am required to inform Fujioka Family Dentistry at least 24 hours in advance. If 24 hour notice is not given, I will be charged a $50 cancellation fee.

I acknowledge that I have reviewed the Statement of Privacy Practices

I have read the Statement of Privacy PracticesSignature (Please Type Full Name):

Adult Patient Parent or Guardian Spouse

Date

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