Patient Registration

Confidential Patient Information

First Name

Last Name

Birthdate

Gender

Address

City

State

Zip

Main Phone

If patient is a minor, give parent's or guardian's name

Financial Party Information

Check if the patient is also the person who will be financially responsible for treatment

First Name

Last Name

Marital Status

Relationship to Patient

Birthdate

Address

City

State

Zip

Main Phone

Spouse or Other Parent's First Name

Last Name

Relationship to Patient

Birthdate

Employer

Occupation

Length of Employment

Work Phone #

Insurance Information

Policy Holder's Name

Relationship to Patient

Policy Holder's Employer

Subscriber ID #

Subscriber SSN

Birthdate

Group No

Insurance Company

Medical History

Has there been any change in the patient's general health within the last year?

Yes

Is the patient now under the care of a physician (other than routine)? If so, what is being treated?

Yes

Has the patient had a serious illness/hospitalization in the past 5 years? If so, what for?

Yes

List any medications currently being taken by the patient (include non-prescription):

Allergies or drug reaction to:

Latex

Yes

Penicillin or other antibiotics

Yes

Sulfa drugs

Yes

Aspirin, Ibuprofen, Tylenol

Yes

Local anesthetics

Yes

Metal Allergy

Yes

Other

Yes

List any drug allergies or sensitivities (not listed above) that the patient may have:

All answers default to NO. Please select YES if the patient has had any of the conditions listed below either now or in the past.

Heart Murmur

Yes

Damaged or artificial heart valves

Yes

Congenital Heart Defect

Yes

Heart Disease

Yes

Rheumatic Fever

Yes

Angina

Yes

Liver Disease / Jaundice / Hepatitis

Yes

Kidney Disease

Yes

Heart Attack/Stroke

Yes

Hemophilia

Yes

Hypertension/High Blood Pressure

Yes

Prolonged Bleeding/Transfusion

Yes

Anemia / Blood disorder

Yes

HIV/AIDS

Yes

Tonsils/Adenoids Removed

Yes

Handicaps/Disabilities

Yes

Arthritis / Joint problems

Yes

Large Tonsils

Yes

Sinus trouble

Yes

Substance abuse problem (past or present)

Yes

Bone fractures/trauma to face/jaw

Yes

Prosthetic joints

Yes

Chronic fatigue

Yes

Diabetes

Yes

Growth Problems

Yes

Tuberculosis or Lung Disease

Yes

Pneumonia

Yes

Cancer

Yes

Family History of Cancer

Yes

Received Radiation Treatment

Yes

Arteriosclerosis

Yes

Thyroid / Endocrine Problems

Yes

Stomach ulcer or hyperacidity

Yes

Hormone Therapy

Yes

Metal Allergy

Yes

Nervous Disorders

Yes

Bone Disorders/Bone Loss

Yes

Seizures / Epilepsy / Neurological Disease

Yes

Treated for Emotional Problems

Yes

Asthma

Yes

Respiratory problems / Emphysema

Yes

Persistent swollen neck glands

Yes

Low blood pressure

Yes

FEMALES: Are you pregnant

Yes

Take Bisphosphonates (Fosamax, Boniva)

Yes

If any of the above medical questions were answered 'Yes', please explain:

Is there anything else we should know about the patient to ensure a great experience at our office?

I have reviewed a copy of the Wisconsin Surgery Center Notice of Privacy Practices (click here to review) and certify that I am over the age of 18 or the legal parent or guardian of above named patient, and that have read and understand the above. I acknowledge that I have completed this form to the best of my knowledge, and that my questions have been answered to my satisfaction. I will not hold my orthodontist or any other member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. If there is any change later to this history record or medical status, I will inform the practice.

Signature of patient if over 18 or parent/legal guardian:

Wisconsin Surgery Center, located at 3305 South 20th Street, Suite 150, Milwaukee, WI 53215 is a technologically advanced surgery center for general surgery, gynecologic surgery, orthopedics and pain management procedures, among many others.
Call 414-384-2100 or fax to 414-384-2700.

Patient Registration

Confidential Patient Information

Financial Party Information

Insurance Information

Medical History

Allergies or drug reaction to:

All answers default to NO. Please select YES if the patient has had any of the conditions listed below either now or in the past.

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