PAGE TITLE

ADDRESS
6726 Commonwealth Dr
Loves Park, IL 61111

PHONE
815.633.7220

FAX
815.633.7295

HOURS OF OPERATION
M:
9 - 8PM

T:
9 - 8PM

W:
CLOSED

TH:
8 - 8PM

F:
7 - 1PM

1st Saturday of
every month 9 - 1PM

*We offer appointments outside of our normal business hours in case of emergency or to accomodate special circumstances.




 Bischoff Dentistry
 Patient Registration and Health History
 
If you are a new patient of Dr. Bischoff's, you can fill out and print your Patient Registration form Online. After you print your registration form, just bring it in with you to your appointment and hand it to a patient coordinator at the front desk.

You can fill out this form in 2 different methods: using the form below or by clicking here and download the PDF version of our Patient registration form.

If this appointment is for you (fill in this section)
Date:
Name:
Spouse:
Address:
City State Zip
Home Phone#:
Cell Phone#:
Email:
Date of birth
Gender
Marital Satus
SSN #:
Driver's License #:
If this appointment is for your Child (fill in this section)
Date:
Name:
Address:
City State Zip
Home Phone#:
Cell Phone#:
Email Address:
Date of birth
School: Grade:
SSN #:


Account Information
Person Financially Responsible for Account
Name:
Relationship to patient:
Address:
City State Zip
Home Phone#:
Cell Phone#:
Email Address:
YOU
Name:
Employer:
Business Address:
Business Phone:
YOUR SPOUSE
Name:
Employer:
Business Address:
Business Phone:

Getting to know you
Is another member of your family or relative a patient of our office?
Name:
Relationship:
Referred to us by:
Another Patient or Doctor
Or one of this Yellow Pages Sign Internet


Personal Info
Patient Name  
1) Are you having pain or discomfort at this time? yes no
    
 
2) Have you been a patient in the hospital for the past 2 years? yes no
    
 
3) Have you been under the care of a medical doctor during the past 2 years? yes no
    Physician Name:   Phone:
 
4) Have you taken any medication or drugs during the past 2 years? yes no
    Medication(s) name(s):
 
5) Are you now taken any medications, drug or pills? yes no
    Medication(s) name(s):
 
6) Are you aware of being allergic to or have ever reacted adversely to any medication or substance? yes no
    If so please list:
 
7) Please indicate which of the following you have had or have at present.
Heart Failure yes no Tuberculosis yes no
Heart Disease or attack yes no Asthma yes no
Angina Petcoris yes no Hey Fever yes no
Congenital Heart Disease yes no Allergies or Hives yes no
Heart Murmur yes no Sinus Trouble yes no
High Blood Pressure yes no Radiation Therapy yes no
Arteriosclerosis yes no Chemotherapy yes no
Mitral Valve Prolapse yes no Hepatitis A (infectious) yes no
Artificial Heart Valve yes no Hepatitis B (serum) yes no
Heart Pacemaker yes no Venereal Disease yes no
Heart Surgery yes no A.I.D.S. yes no
Rheumatic Fever yes no H.I.V. Positive yes no
Arthritis yes no Cold Sores/Fever Blisters yes no
Rheumatism yes no Blood Transfusion yes no
Cortisone Medicine yes no Hemophilia yes no
Drug Addiction yes no Anemia yes no
Stroke yes no Sickle Cell Disease yes no
Artificial Joins (hip, knee) yes no Bruise Easily yes no
Kidney Trouble yes no Liver Disease yes no
Ulcers yes no Yellow Jaundice yes no
Diabetes yes no Epilepsy or Seizures yes no
Thyroid Problems yes no Fainting or Dizzy Spells yes no
Glaucoma yes no Nervousness yes no
Cosmetic Surgery yes no Psychiatric Treatment yes no
Emphysema yes no Developmentally Disabled yes no
Chronic Cough yes no Hepatitis C yes no
 
8) When you walk or climb stairs, do you ever have to stop because of pain in your chest? yes no
    
 
9) Do your ankles swell during the day? yes no
    
 
10) Have you ever been or are currently treated for any TMJ Disorder? yes no
    
 
11) Do you have any pain or notice any popping or clicking noise when you eat or yawn? yes no
    
12) Has your medical doctor ever said you have a cancer or tumor? yes no
    
13) Do you have or have you had any disease, condition, or problem not listed? yes no
    If yes, please list
14) For women only, Are you pregnant? yes no
    What Month:
    Are you nursing:
 
I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions truthfully and to the best of my knowledge.
 
Patient signature ________________________________________________
Date: 7/30/2010 8:37:03 PM
  

PDF Version: Patient Registration and Health History Document
 
Please use the link to the right to open (or download) and print this file, so you can filled out and bring it or fax it to us. Open and Print this Document
 
To view and print PDF documents you need Adobe Acrobat Reader installed in your computer, if you do not have it, please downloaded from this link. Download Acrobat Reader

 











OFFICE HOURS       M 9 - 8
PM
     T 9 - 8
PM
      W CLOSED     TH 8 - 8
PM
     F 7 - 1
PM
Bischoff Dentistry    6726 Commonwealth Dr Loves Park, IL 61111     815.633.7220 Copyright © 2010 - 2011 | Privacy Policy

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