Fujioka Family Dentistry

Patient Forms

New Sleep Patient Registration Form

Complete the form below before your visit. If you have questions, please call Fujioka Family Dentistry at 360-696-4439.

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required field — please fill out all required fields.

This form may contain sensitive personal or health information. Submission details are not included in notification emails.

Name: required
Gender: required
Mailing Address: required
Employer address:
Status:

INSURANCE INFO

Primary Medical Insurance / Medicare Insurance

Company address:

Secondary Medical Insurance / Supplemental Medicare Insurance

Company address:

ACCOUNT INFO

Person ultimately responsible for the account
Name: required
Billing address: required
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

DENTAL INFORMATION

SLEEP INFORMATION

Have you had a sleep study done? required

MEDICAL HISTORY

Are you under a physician's care now? required
Have you ever been hospitalized or had a major operation? required
Have you ever had a serious head or neck injury? required
Are you taking any medications, pills or drugs? required
Do you take, or have you taken, Phen-Fen or Redux? required
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? required
Do you use tobacco? required
Do you use controlled substances? required
Do you use marijuana? required
WOMEN:
Are you Pregnant/Trying to get pregnant? required
Taking Oral Contraceptives? required
Nursing? required
Do you take herbal supplements or other OTC products ex: fish oil or vitamins? required
Are you allergic to any of the following? required

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

AIDS/HIV Positive required
Alzheimer's Disease required
Anaphylaxis required
Anemia required
Angina required
Anxiety required
Arthritis / Gout required
Artificial Heart Valve required
Artificial Joint required
Asthma required
Blood Disease required
Blood Transfusion required
Breathing Problem required
Bruise Easily required
Cancer required
Chemotherapy required
Chest Pains required
Cold Sores / Fever Blisters required
Congenital Heart Disorder required
Cortisone Medicine required
Depression required
Diabetes required
Drug Addiction required
Emphysema required
Epilepsy or Seizures required
Excessive Bleeding required
Excessive Thirst required
Fainting Spells / Dizziness required
Frequent Cough required
Frequent Headaches required
Dementia required
Glaucoma required
Hay Fever required
Heart Attack / Failure required
Heart Murmur required
Heart Pacemaker required
Heart Trouble / Disease required
Hemophilia required
Hepetitis A required
Hepetitis B or C required
Herpes required
High Blood Pressure required
High Cholesterol required
Hives or Rash required
Hypoglycemia required
Irregular Heartbeat required
Kidney Problems required
Leukemia required
Liver Disease required
Low Blood Pressure required
Lung Disease required
Mitral Valve Prolapse required
Osteoporosis required
Pain in Jaw Joints required
Parathyroid Disease required
Parkinson's Disease required
Psychiatric Care required
Radiation Treatments required
Renal Dialysis required
Rheumatic Fever required
Rheumatism required
Scarlet Fever required
Shingles required
Sickle Cell Disease required
Sinus Trouble required
Spina Bifida required
Stomach / Intestinal Disease required
Stroke required
Thyroid Disease required
Tonsillitis required
Tuberculosis required
Tumors or Growths required
Ulcers required
Venereal Disease required
Have you ever had any serious illness not listed above?
Please check the required boxes: required
Required acknowledgement
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I acknowledge that I have reviewed the Statement of Privacy Practices

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