New Patient Registration

Irish Dental Registration Form

Mailing Address

Insurance Policy Information

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    Max. file size: 256 MB.

      Secondary Policy Information (If Applicable)

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      Max. file size: 256 MB.

        Primary Care Physician's Information

        Pharmacy Information

        Previous Dental Office Information

        Medical History

        Are you under a physician's care?
        Do you routinely take health related substances (vitamins, herbal supplements, natural products)?
        Do you have any problems with penicillin, antibiotics, anesthetics or other medications?
        Are you sensitive to any metals or latex?
        Are you pregnant or suspect you may be?
        Do you use any birth control medications?
        Have you ever been treated for or been told you might have heart disease?
        Do you have a pacemaker, an artificial heart valve implant, or been diagnosed with mitral valve prolapse?
        Have you ever had rheumatic fever?
        Are you aware of any heart murmurs?
        Do you have high or low blood pressure?
        Have you ever taken Fosamax, Zometa, Aredia or any other oral or intravenous treatment (bisphosphonates) for bone tumors, excessive calcium in your blood, or osteoporosis?
        Do you have inflammatory diseases, such as arthritis or rheumatism?
        Do you have any artificial joints/prosthesis?
        Do you have any blood disorders, such as anemia, leukemia, etc?
        Have you ever bled excessively after being cut or injured?
        Do you have any stomach problems?
        Do you have any kidney problems?
        Do you have any liver problems?
        Are you diabetic?
        Do you have fainting or dizzy spells?
        Do you have asthma?
        Do you have epilepsy or seizure disorders?
        Do you or have you had venereal or any sexually transmitted disease?
        Have you tested HIV positive?
        Do you have AIDS?
        Have you had or do you test positive for hepatitis?
        Do you smoke, chew, use snuff or any other forms of tobacco?
        Do you regularly consume more than one or two alcoholic beverages a day?
        Do you habitually use controlled substances?
        Have you had psychiatric treatment?
        Have you taken the prescription drugs fenfluramine or fenfluramine?
        Please enter the name of the person who filled out this registration form. By entering your name you are electronically signing this document.

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        Irish Dental

        25 Hospital Center Blvd #102, Hilton Head Island, SC 29926, USA
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