Dr. Iván E. Rodriguez

Harlingen Office Address, 1610 East Harrison Ave,

suite A, Harlingen, Texas 78550

956-412-9500

Patient Registration

Drs. Rodriguez and Trevino Welcome You

Root canal therapy is an attempt to save a tooth which otherwise may require extraction. We need certain information about you to make treatment as safe and successful as possible. Please read and fill out both sides carefully. If you have questions, be sure they are answered before signing this form.

Patient's Name

Phone

Address

Apt #

City

State

Zip

Soc. Sec. No

Birth date

Driver's Lic. No

Exp.

If minor, Guardian's name

Birth date

Relationship

Dental Insurance

Yes No

BCBS ofTX

MetLife Aetna Humana Delta Dental Guardian Ameritas Other

Name of Employer

Dept.

Work Phone

Ext

Employer's Address

E-MAIL address

Spouse Name

DOB:

Cell Phone::

Spouse's Employer

Employer's Address:

Person to contact in case of an emergency

Phone

Whom may we thank for referring you?

General health (make a check mark):

Excellent Good Fair Poor

Name of Physician

Date of last Physical examination

Any major change in health during the past year?

Yes No

Do you have any other medical problem(s) not listed above?

Yes No

Select if you are allergic to:

Aspirin Penicillin Codeine Latex Local anesthetic Other

Allergies to any other medications, not listed above?

Please list below any medications you are presently taking: (Name, for what condition?)

Explain in your words the reason of today’s visit

Is your visit due to an accident?

Yes No

If yes, please explain and date of accident

AN X-RAY(S) IS NECESSARY TODAY, TO ESTABLISH A COMPLETE DIAGNOSIS.

Where does it hurt?

Right Left Upper Lower

Have you had this problem (or similar problem) before?

Yes No

If yes, please explain

On scale of0-10, where would you rate you discomfort? (10 = most discomfort)

Is it a sharp pain or is it more like a dull ache?

sharp dull

Does it throb, hurt, or is it more of a steady unchanging pain?

throb steady hurt

Does it hurt all the time or does it start and stop?

all time start & stop

Does it interfere with your sleep?

Yes No

Does anything make the pain worse?

Yes No

What?

Have you taken aspirin or any other medication?

Yes No

Does the medication help?

Yes No

Consent Form:

I have reviewed the health history and believe it to be correct. If there is a change in health or in medications taken, I will inform the doctor at my next appointment. I consent to treatment by the health care providers of this dental practice.

Signature of Patient or (Parent's if minor)

Use your mouse cursor or the tip of your finger to sign below

Date:

Doctor's Signature

Use your mouse cursor or the tip of your finger to sign below

Date:

Assistant's initials

CONSENT TO RECEIVING PRIVACY NOTICE

ASSIGNMENT OF INSURANCE BENEFITS

CONSENT FOR EVALUATION

I was given the opportunity to read the Privacy Notice and object to disclosures of my protected health information.

I authorize that I am financially responsible for all charges whether or not paid by insurance.

I authori ze my insurance company to pay to the dentist all insurance benefits otherwise payable to me for services rendered. l authorize the use of this signature on all insurance submissions.

I authorize the dentist to release all information concerning my health care, advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits.

I permit a copy of this authorization to be used in place of the original.

Patient's Signature or (Parent's if minor)

Use your mouse cursor or the tip of your finger to sign below

Date:

Woman Only

Are you presently pregnant?

Yes No

Are you presently taking oral contraceptives?

Yes No

If so, read and sign the following:

Information and consent form patients taking oral contraceptives

It has been explained to me, and I understand, that oral antibiotics (and certain other medications) may interfere with the effectiveness of oral contraceptives. Therefore, I understand that I will need to use some additional form of birth control for one complete cycle of birth control pills after my course of antibiotics or other medication is completed.

Parent's Signature:

Use your mouse cursor or the tip of your finger to sign below

Date: