Adult Patient Form

Adult Registration Form - Dental - v2

Patient Information


Spouse / Partner Information

Marital Status

Person(s) OK to release appointment or medically related information to concerning you:

Insurance Information

Dental History

How did you hear about our Practice?
Have your tonsils or adenoids been removed?
Have you ever experienced jaw joint pain/ discomfort (TMJ/TMD)?
Do you have any missing or extra permanent teeth?
Have you ever had an injury to (select all that apply):
Do you have speech problems?
Do your gums bleed?
Do you smoke?
Do you like your smile?
Do you currently or have you ever had any of the following habits (check all that apply)

Radiograph / X-Ray Information

If you answered YES to any of the questions you will need to retrieve these radiographs prior to any treatment to prevent over exposure to radiation and to decrease the chance of incurring an additional charge for a non‐covered service. You should request these items and bring them with you to your next appointment, (having them in hand prevents the lost in mail syndrome). These questions were included in your new patient packet that was sent to you when you set up your first exam visit.

Medical History

Are you currently being treated by a physician?
Have you ever been hospitalized or had a major operation? If yes, describe:
Have you ever had a serious head or neck injury? If yes, describe:
Are you currently taking any prescription or over-the-counter medications?
Do you take, or have you taken. Phen-Fen or Redux?
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
Are you on a special diet?
Do you use tobacco?
Do you use controlled substances?

Are you allergic to any of the following?

Check if you have or have ever had any of the following:

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status.

I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.

I understand that where appropriate, credit bureau reports may be obtained.

Security Measure

J. A. Lewandowski, D.D.S.

  • J. A. Lewandowski, D.D.S. - 13401 Mission Rd., Suite 212, Leawood, KS 66209 Phone: 913-851-8000

2019 © All Rights Reserved | Privacy Policy | Website Design By: West | Login