{"id":2199,"date":"2026-03-31T01:36:41","date_gmt":"2026-03-31T01:36:41","guid":{"rendered":"https:\/\/project1.1stopwebsitesolution.com\/kokiniasdental\/?page_id=2199"},"modified":"2026-04-08T23:46:03","modified_gmt":"2026-04-08T23:46:03","slug":"dean-j-kokinias-d-d-s-patient-registration-and-health-history","status":"publish","type":"page","link":"https:\/\/project1.1stopwebsitesolution.com\/kokiniasdental\/dean-j-kokinias-d-d-s-patient-registration-and-health-history\/","title":{"rendered":"DEAN J. KOKINIAS, D.D.S. Patient Registration and Health History"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"2199\" class=\"elementor elementor-2199\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-1a6adc7 e-flex e-con-boxed e-con e-parent\" data-id=\"1a6adc7\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-ea11901 e-con-full e-flex e-con e-child\" data-id=\"ea11901\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t<div class=\"elementor-element elementor-element-a1d145e e-con-full e-flex e-con e-child\" data-id=\"a1d145e\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-b9f9d60 elementor-widget__width-inherit elementor-widget-tablet__width-inherit elementor-widget elementor-widget-heading\" data-id=\"b9f9d60\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">DEAN J. KOKINIAS, D.D.S.<br>\nPatient Registration and Health History<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-e922274 e-flex e-con-boxed e-con e-parent\" data-id=\"e922274\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-1dea6b5 elementor-widget elementor-widget-text-editor\" data-id=\"1dea6b5\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t        <div class=\"page custom-form-2\">\n                    \t\t<form action=\"https:\/\/project1.1stopwebsitesolution.com\/kokiniasdental\/wp-admin\/admin-post.php\" method=\"post\" novalidate>\n\t\t\t<input type=\"hidden\" name=\"action\" value=\"custom_forms_submit\">\n\t\t\t<input type=\"hidden\" name=\"form_key\" value=\"patient_info\">\n\t\t\t<input type=\"hidden\" id=\"custom_forms_nonce\" name=\"custom_forms_nonce\" value=\"1c4edc66c8\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/kokiniasdental\/wp-json\/wp\/v2\/pages\/2199\" \/>\t\t\t<input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/kokiniasdental\/wp-json\/wp\/v2\/pages\/2199\">\n\t\t\n            <h1 class=\"form-heading\" id=\"patient-heading\">\n              Patient Information\n              <span class=\"confidential\">(All Information Will Be Kept Strictly Confidential)<\/span>\n            <\/h1>\n            <section class=\"form-block\" aria-labelledby=\"patient-heading\">\n              <div class=\"row-3\">\n                <div class=\"field\">\n                  <label for=\"patient_name\">Name<\/label>\n                  <input type=\"text\" id=\"patient_name\" name=\"patient_name\" value=\"\" placeholder=\"Enter Name\" maxlength=\"120\" autocomplete=\"name\"  \/>\n                <\/div>\n                <div class=\"field\">\n                  <label for=\"patient_birthdate\">Birthdate<\/label>\n                  <input type=\"text\" id=\"patient_birthdate\" name=\"patient_birthdate\" value=\"\" placeholder=\"Enter Date\" maxlength=\"32\" autocomplete=\"bday\"  \/>\n                <\/div>\n                <div class=\"field\">\n                  <label for=\"patient_street\">Street Address<\/label>\n                  <input type=\"text\" id=\"patient_street\" name=\"patient_street\" value=\"\" placeholder=\"Enter Street Address\" maxlength=\"200\" autocomplete=\"street-address\"  \/>\n                <\/div>\n              <\/div>\n\n              <div class=\"row-4\">\n                <div class=\"field gender-field\">\n                  <label>Gender<\/label>\n                  <div class=\"gender-wrap\">\n                    <label class=\"check-inline\"><input type=\"radio\" name=\"patient_gender\" value=\"male\"> Male<\/label>\n                    <label class=\"check-inline\"><input type=\"radio\" name=\"patient_gender\" value=\"female\"> Female<\/label>\n                  <\/div>\n                <\/div>\n                <div class=\"field\">\n                  <label for=\"patient_city\">City<\/label>\n                  <input type=\"text\" id=\"patient_city\" name=\"patient_city\" value=\"\" placeholder=\"Enter City\" maxlength=\"80\" autocomplete=\"address-level2\"  \/>\n                <\/div>\n                <div class=\"field\">\n                  <label for=\"patient_state\">State<\/label>\n                  <input type=\"text\" id=\"patient_state\" name=\"patient_state\" value=\"\" placeholder=\"Enter State\" maxlength=\"32\" autocomplete=\"address-level1\"  \/>\n                <\/div>\n                <div class=\"field\">\n                  <label for=\"patient_zip\">ZIP<\/label>\n                  <input type=\"text\" id=\"patient_zip\" name=\"patient_zip\" value=\"\" placeholder=\"Enter ZIP\" maxlength=\"16\" inputmode=\"numeric\" autocomplete=\"postal-code\"  \/>\n                <\/div>\n              <\/div>\n\n              <div class=\"checkbox-row\">\n                <span class=\"inline-label\">Check Appropriate Box:<\/span>\n                <label class=\"check-inline\"><input type=\"checkbox\" name=\"patient_marital[]\" value=\"minor\"  \/> Minor<\/label>\n                <label class=\"check-inline\"><input type=\"checkbox\" name=\"patient_marital[]\" value=\"single\"  \/> Single<\/label>\n                <label class=\"check-inline\"><input type=\"checkbox\" name=\"patient_marital[]\" value=\"married\"  \/> Married<\/label>\n                <label class=\"check-inline\"><input type=\"checkbox\" name=\"patient_marital[]\" value=\"divorced\"  \/> Divorced<\/label>\n                <label class=\"check-inline\"><input type=\"checkbox\" name=\"patient_marital[]\" value=\"widowed\"  \/> Widowed<\/label>\n              <\/div>\n\n              <div class=\"responsible-row\">\n                <div class=\"wide-field\">\n                  <label for=\"account_responsible_name\">Name Of Person Responsible For Your Account:<\/label>\n                  <input type=\"text\" id=\"account_responsible_name\" placeholder=\"Enter Name Of Person Responsible For Your Account:\" name=\"account_responsible_name\" value=\"\" maxlength=\"120\"  \/>\n                <\/div>\n                <div class=\"checkbox-row\">\n                  <span class=\"inline-label\">Relationship<\/span>\n                  <label class=\"check-inline\"><input type=\"checkbox\" name=\"account_relationship[]\" value=\"self\"  \/> Self<\/label>\n                  <label class=\"check-inline\"><input type=\"checkbox\" name=\"account_relationship[]\" value=\"mother\"  \/> Mother<\/label>\n                  <label class=\"check-inline\"><input type=\"checkbox\" name=\"account_relationship[]\" value=\"father\"  \/> Father<\/label>\n                  <label class=\"check-inline\"><input type=\"checkbox\" name=\"account_relationship[]\" value=\"guardian\"  \/> Guardian<\/label>\n                <\/div>\n              <\/div>\n\n              <div class=\"row-3\">\n                <div class=\"field\">\n                  <label for=\"insured_name\">Insured&#8217;s Name:<\/label>\n                  <input type=\"text\" id=\"insured_name\" name=\"insured_name\" value=\"\" placeholder=\"Enter Insured's Name\" maxlength=\"120\" autocomplete=\"off\"  \/>\n                <\/div>\n                <div class=\"field\">\n                  <label for=\"insured_ssn\">Insured&#8217;s SSN<\/label>\n                  <input type=\"text\" id=\"insured_ssn\" name=\"insured_ssn\" value=\"\" placeholder=\"Enter Insured's SSN\" maxlength=\"11\" inputmode=\"numeric\" autocomplete=\"off\"  \/>\n                <\/div>\n                <div class=\"field\">\n                  <label for=\"insured_dob\">Insured&#8217;s DOB<\/label>\n                  <input type=\"text\" id=\"insured_dob\" name=\"insured_dob\" value=\"\" placeholder=\"Enter Insured's DOB\" maxlength=\"32\" autocomplete=\"off\"  \/>\n                <\/div>\n              <\/div>\n\n              <div class=\"row-3\">\n                <div class=\"field\">\n                  <label for=\"emergency_contact\">Emergency Contact:<\/label>\n                  <input type=\"text\" id=\"emergency_contact\" name=\"emergency_contact\" value=\"\" placeholder=\"Enter Emergency Contact\" maxlength=\"120\"  \/>\n                <\/div>\n                <div class=\"field\">\n                  <label for=\"emergency_cell\">Cell Phone<\/label>\n                  <input type=\"tel\" id=\"emergency_cell\" name=\"emergency_cell\" value=\"\" placeholder=\"Enter Cell Phone\" maxlength=\"32\" autocomplete=\"tel\"  \/>\n                <\/div>\n                <div class=\"field\">\n                  <label for=\"emergency_relationship\">Relationship<\/label>\n                  <input type=\"text\" id=\"emergency_relationship\" placeholder=\"Enter Relationship\" name=\"emergency_relationship\" value=\"\" maxlength=\"60\"  \/>\n                <\/div>\n              <\/div>\n\n              <div class=\"responsible-row\">\n                <div class=\"wide-field\">\n                  <label for=\"referred_by\">Referred By? (Name)<\/label>\n                  <input type=\"text\" id=\"referred_by\" placeholder=\"Enter Referred By? (Name)\" name=\"referred_by\" value=\"\" maxlength=\"120\"  \/>\n                <\/div>\n                <div class=\"checkbox-row\">\n                  <span class=\"inline-label\">Relationship<\/span>\n                  <label class=\"check-inline\"><input type=\"checkbox\" name=\"referral_relationship[]\" value=\"relative\"  \/> Relative<\/label>\n                  <label class=\"check-inline\"><input type=\"checkbox\" name=\"referral_relationship[]\" value=\"friend\"  \/> Friend<\/label>\n                  <label class=\"check-inline\"><input type=\"checkbox\" name=\"referral_relationship[]\" value=\"coworker\"  \/> Co-worker<\/label>\n                  <label class=\"check-inline\"><input type=\"checkbox\" name=\"referral_relationship[]\" value=\"google\"  \/> Google<\/label>\n                <\/div>\n              <\/div>\n            <\/section>\n\n            <h2 class=\"form-heading dental-med\" id=\"dental-heading\">Dental History<\/h2>\n            <section class=\"form-block\" aria-labelledby=\"dental-heading\">\n              <div class=\"dental-date-line\">\n                <span class=\"prompt\">Date of last Dental checkup and cleaning<\/span>\n                <span class=\"date-slots\">\n                  <input type=\"text\" class=\"date-slot\" name=\"last_cleaning_dd\" value=\"\" id=\"last_cleaning_dd\" maxlength=\"2\" inputmode=\"numeric\" aria-label=\"Day of last cleaning\"  \/>\n                  <span class=\"date-sep\">\/<\/span>\n                  <input type=\"text\" class=\"date-slot\" name=\"last_cleaning_mm\" value=\"\" id=\"last_cleaning_mm\" maxlength=\"2\" inputmode=\"numeric\" aria-label=\"Month of last cleaning\"  \/>\n                  <span class=\"date-sep\">\/<\/span>\n                  <input type=\"text\" class=\"date-slot year-slot\" name=\"last_cleaning_yyyy\" value=\"\" id=\"last_cleaning_yyyy\" maxlength=\"4\" inputmode=\"numeric\" aria-label=\"Year of last cleaning\"  \/>\n                <\/span>\n              <\/div>\n\n              <p class=\"condition-intro\">Do You Have Or Have You Had Any Of The Following, Please Check all that apply<\/p>\n              <div class=\"cols-3\">\n                <ul class=\"cond-list\">\n                  <li><label><input type=\"checkbox\" name=\"dental[]\" value=\"teeth_sensitive\"  \/> Teeth sensitive to cold, heat, sweets, or pressure<\/label><\/li>\n                  <li><label><input type=\"checkbox\" name=\"dental[]\" value=\"bleeding_gums\"  \/> Bleeding gums<\/label><\/li>\n                  <li><label><input type=\"checkbox\" name=\"dental[]\" value=\"clenching_grinding\"  \/> Teeth clenching or grinding<\/label><\/li>\n                  <li><label><input type=\"checkbox\" name=\"dental[]\" value=\"extraction_complications\"  \/> Complications from extractions<\/label><\/li>\n                  <li><label><input type=\"checkbox\" name=\"dental[]\" value=\"swelling_lumps\"  \/> Swelling or lumps in mouth<\/label><\/li>\n                <\/ul>\n                <ul class=\"cond-list\">\n                  <li><label><input type=\"checkbox\" name=\"dental[]\" value=\"cold_sores\"  \/> Frequent cold sores<\/label><\/li>\n                  <li><label><input type=\"checkbox\" name=\"dental[]\" value=\"jaw_click_pop\"  \/> Clicking or popping of jaw<\/label><\/li>\n                  <li><label><input type=\"checkbox\" name=\"dental[]\" value=\"unfavorable_dental\"  \/> Unfavorable dental experience<\/label><\/li>\n                  <li><label><input type=\"checkbox\" name=\"dental[]\" value=\"blisters\"  \/> Frequent blisters on lips or in mouth<\/label><\/li>\n                  <li><label><input type=\"checkbox\" name=\"dental[]\" value=\"orthodontic\"  \/> Orthodontic Treatment<\/label><\/li>\n                <\/ul>\n                <ul class=\"cond-list\">\n                  <li><label><input type=\"checkbox\" name=\"dental[]\" value=\"burning_tongue\"  \/> Burning of tongue<\/label><\/li>\n                  <li><label><input type=\"checkbox\" name=\"dental[]\" value=\"bad_breath\"  \/> Bad breath<\/label><\/li>\n                  <li><label><input type=\"checkbox\" name=\"dental[]\" value=\"unpleasant_taste\"  \/> Unpleasant taste<\/label><\/li>\n                  <li><label><input type=\"checkbox\" name=\"dental[]\" value=\"wisdom_pain\"  \/> Wisdom tooth pain<\/label><\/li>\n                <\/ul>\n              <\/div>\n\n              <div class=\"discuss-row\">\n                <span class=\"inline-label\">I would like to discuss?<\/span>\n                <label class=\"check-inline\"><input type=\"checkbox\" name=\"discuss[]\" value=\"smile\"  \/> Enhancing my smile<\/label>\n                <label class=\"check-inline\"><input type=\"checkbox\" name=\"discuss[]\" value=\"whitening\"  \/> Whitening my teeth<\/label>\n                <label class=\"check-inline\"><input type=\"checkbox\" name=\"discuss[]\" value=\"ortho_invisalign\"  \/> Orthodontics\/Invisalign<\/label>\n              <\/div>\n\n              <div class=\"yesno-row radio-upper\">\n                <div class=\"group\">\n                  <span class=\"inline-label\">Have you ever been diagnosed with sleep apnea?<\/span>\n                  <label class=\"check-inline\"><input type=\"radio\" name=\"sleep_apnea_diagnosed\" value=\"yes\"> Yes<\/label>\n                  <label class=\"check-inline\"><input type=\"radio\" name=\"sleep_apnea_diagnosed\" value=\"no\"> No<\/label>\n                <\/div>\n                <div class=\"group\">\n                  <span class=\"inline-label\">Sleep study performed?<\/span>\n                  <label class=\"check-inline\"><input type=\"radio\" name=\"sleep_study_performed\" value=\"yes\"> Yes<\/label>\n                  <label class=\"check-inline\"><input type=\"radio\" name=\"sleep_study_performed\" value=\"no\"> No<\/label>\n                <\/div>\n              <\/div>\n            <\/section>\n\n            <h2 class=\"form-heading dental-med\" id=\"medical-heading\">Medical History<\/h2>\n            <section class=\"form-block\" aria-labelledby=\"medical-heading\">\n              <div class=\"med-top\">\n                <div class=\"field\">\n                  <label for=\"physician_name\">Physician&#8217;s Name<\/label>\n                  <input type=\"text\" class=\"line-under\" id=\"physician_name\" name=\"physician_name\" value=\"\" maxlength=\"120\"  \/>\n                <\/div>\n                <div class=\"field\">\n                  <label for=\"physician_phone\">Office Phone<\/label>\n                  <input type=\"tel\" class=\"line-under\" id=\"physician_phone\" name=\"physician_phone\" value=\"\" maxlength=\"32\"  \/>\n                <\/div>\n                <div class=\"field\">\n                  <label for=\"last_physical\">Date Of Last Physical Exam<\/label>\n                  <input type=\"text\" class=\"line-under\" id=\"last_physical\" name=\"last_physical\" value=\"\" maxlength=\"64\"  \/>\n                <\/div>\n              <\/div>\n\n              <p class=\"allergy-intro\">Are You Allergic To Any Of The Following? (Check All That Apply)<\/p>\n              <div class=\"allergy-pills\">\n                <label class=\"allergy-pill\"><input type=\"checkbox\" name=\"allergy[]\" value=\"aspirin\"  \/><span class=\"pill-text\">Aspirin<\/span><\/label>\n                <label class=\"allergy-pill\"><input type=\"checkbox\" name=\"allergy[]\" value=\"penicillin\"  \/><span class=\"pill-text\">Penicillin<\/span><\/label>\n                <label class=\"allergy-pill\"><input type=\"checkbox\" name=\"allergy[]\" value=\"codeine\"  \/><span class=\"pill-text\">Codeine<\/span><\/label>\n                <label class=\"allergy-pill\"><input type=\"checkbox\" name=\"allergy[]\" value=\"sulfa\"  \/><span class=\"pill-text\">Sulfa<\/span><\/label>\n                <label class=\"allergy-pill\"><input type=\"checkbox\" name=\"allergy[]\" value=\"acrylics\"  \/><span class=\"pill-text\">Acrylics<\/span><\/label>\n                <label class=\"allergy-pill\"><input type=\"checkbox\" name=\"allergy[]\" value=\"metals\"  \/><span class=\"pill-text\">Metals<\/span><\/label>\n                <label class=\"allergy-pill\"><input type=\"checkbox\" name=\"allergy[]\" value=\"latex\"  \/><span class=\"pill-text\">Latex<\/span><\/label>\n                <label class=\"allergy-pill\"><input type=\"checkbox\" name=\"allergy[]\" value=\"local_anesthetics\"  \/><span class=\"pill-text\">Local Anesthetics<\/span><\/label>\n              <\/div>\n\n              <div class=\"other-allergies\">\n                <span class=\"inline-label\">Other Allergies:<\/span>\n                <input type=\"text\" class=\"line-under\" name=\"other_allergies\" value=\"\" maxlength=\"500\"  \/>\n              <\/div>\n\n              <p class=\"condition-intro\">Do You Have Or Have You Had Any Of The Following, Please Check all that apply<\/p>\n              <div class=\"cols-3\">\n                <ul class=\"cond-list\">\n                  <li><label><input type=\"checkbox\" name=\"medical[]\" value=\"radiation\"  \/> Radiation treatments<\/label><\/li>\n                  <li><label><input type=\"checkbox\" name=\"medical[]\" value=\"excessive_bleeding\"  \/> Excessive bleeding from cut or extraction<\/label><\/li>\n                  <li><label><input type=\"checkbox\" name=\"medical[]\" value=\"high_bp\"  \/> High blood pressure<\/label><\/li>\n                  <li><label><input type=\"checkbox\" name=\"medical[]\" value=\"low_bp\"  \/> Low blood pressure<\/label><\/li>\n                  <li><label><input type=\"checkbox\" name=\"medical[]\" value=\"heart_murmur\"  \/> Heart murmur<\/label><\/li>\n                  <li><label><input type=\"checkbox\" name=\"medical[]\" value=\"mitral_valve\"  \/> Mitral valve prolapse<\/label><\/li>\n                  <li><label><input type=\"checkbox\" name=\"medical[]\" value=\"artificial_heart_joints\"  \/> Artificial heart valves or joints<\/label><\/li>\n                  <li><label><input type=\"checkbox\" name=\"medical[]\" value=\"other_heart\"  \/> Any other heart ailment<\/label><\/li>\n                  <li><label><input type=\"checkbox\" name=\"medical[]\" value=\"neurological\"  \/> Neurological problems<\/label><\/li>\n                  <li><label><input type=\"checkbox\" name=\"medical[]\" value=\"ulcer_colitis\"  \/> Ulcer or colitis<\/label><\/li>\n                <\/ul>\n                <ul class=\"cond-list\">\n                  <li><label><input type=\"checkbox\" name=\"medical[]\" value=\"hepatitis\"  \/> Hepatitis or liver disease<\/label><\/li>\n                  <li><label><input type=\"checkbox\" name=\"medical[]\" value=\"cancer\"  \/> Cancer<\/label><\/li>\n                  <li><label><input type=\"checkbox\" name=\"medical[]\" value=\"anemia\"  \/> Anemia or blood problems<\/label><\/li>\n                  <li><label><input type=\"checkbox\" name=\"medical[]\" value=\"arthritis\"  \/> Arthritis<\/label><\/li>\n                  <li><label><input type=\"checkbox\" name=\"medical[]\" value=\"asthma\"  \/> Asthma<\/label><\/li>\n                  <li><label><input type=\"checkbox\" name=\"medical[]\" value=\"hay_fever\"  \/> Hay fever or allergies in general<\/label><\/li>\n                  <li><label><input type=\"checkbox\" name=\"medical[]\" value=\"diabetes\"  \/> Diabetes<\/label><\/li>\n                  <li><label><input type=\"checkbox\" name=\"medical[]\" value=\"kidney\"  \/> Kidney problems<\/label><\/li>\n                  <li><label><input type=\"checkbox\" name=\"medical[]\" value=\"thyroid\"  \/> Thyroid disease<\/label><\/li>\n                  <li><label><input type=\"checkbox\" name=\"medical[]\" value=\"epilepsy\"  \/> Epilepsy<\/label><\/li>\n                <\/ul>\n                <ul class=\"cond-list\">\n                  <li><label><input type=\"checkbox\" name=\"medical[]\" value=\"rheumatic_fever\"  \/> Rheumatic fever<\/label><\/li>\n                  <li><label><input type=\"checkbox\" name=\"medical[]\" value=\"sinus\"  \/> Sinus problems<\/label><\/li>\n                  <li><label><input type=\"checkbox\" name=\"medical[]\" value=\"respiratory\"  \/> Respiratory disease<\/label><\/li>\n                  <li><label><input type=\"checkbox\" name=\"medical[]\" value=\"stroke\"  \/> Stroke<\/label><\/li>\n                  <li><label><input type=\"checkbox\" name=\"medical[]\" value=\"tuberculosis\"  \/> Tuberculosis<\/label><\/li>\n                  <li><label><input type=\"checkbox\" name=\"medical[]\" value=\"herpes\"  \/> Herpes\/venereal disease<\/label><\/li>\n                  <li><label><input type=\"checkbox\" name=\"medical[]\" value=\"hiv\"  \/> HIV Positive<\/label><\/li>\n                  <li><label><input type=\"checkbox\" name=\"medical[]\" value=\"aids\"  \/> A.I.D.S.<\/label><\/li>\n                <\/ul>\n              <\/div>\n\n              <div class=\"yesno-row radio-upper\">\n                <span class=\"inline-label\">Do you require pre-medication for your dental visits?<\/span>\n                <label class=\"check-inline\"><input type=\"radio\" name=\"premed\" value=\"yes\"> Yes<\/label>\n                <label class=\"check-inline\"><input type=\"radio\" name=\"premed\" value=\"no\"> No<\/label>\n                <label class=\"check-inline\"><input type=\"radio\" name=\"premed\" value=\"unknown\"> I Don&#8217;t Know<\/label>\n              <\/div>\n\n              <div class=\"meds-single\">\n                <span class=\"inline-label\">List any medications you are currently taking?<\/span>\n                <input type=\"text\" class=\"line-under\" id=\"medications_current\" name=\"medications_current\" value=\"\" maxlength=\"400\"  \/>\n              <\/div>\n\n              <div class=\"yesno-row radio-upper\">\n                <div class=\"group\">\n                  <span class=\"inline-label\">Are you currently under the care of a physician?<\/span>\n                  <label class=\"check-inline\"><input type=\"radio\" name=\"under_physician_care\" value=\"yes\"> Yes<\/label>\n                  <label class=\"check-inline\"><input type=\"radio\" name=\"under_physician_care\" value=\"no\"> No<\/label>\n                <\/div>\n                <div class=\"group physician-condition-group\">\n                  <span class=\"inline-label\">For what condition?<\/span>\n                  <input type=\"text\" class=\"line-under inline\" name=\"physician_care_condition\" value=\"\" maxlength=\"200\"  \/>\n                <\/div>\n              <\/div>\n\n              <div class=\"women-row radio-upper\">\n                <div class=\"group\">\n                  <span class=\"inline-label\">(Women only) Are you pregnant?<\/span>\n                  <label class=\"check-inline\"><input type=\"radio\" name=\"pregnant\" value=\"yes\"> Yes<\/label>\n                  <label class=\"check-inline\"><input type=\"radio\" name=\"pregnant\" value=\"no\"> No<\/label>\n                <\/div>\n                <div class=\"group\">\n                  <span class=\"inline-label\">Nursing?<\/span>\n                  <label class=\"check-inline\"><input type=\"radio\" name=\"nursing\" value=\"yes\"> Yes<\/label>\n                  <label class=\"check-inline\"><input type=\"radio\" name=\"nursing\" value=\"no\"> No<\/label>\n                <\/div>\n                <div class=\"group\">\n                  <span class=\"inline-label\">Taking birth control pills?<\/span>\n                  <label class=\"check-inline\"><input type=\"radio\" name=\"birth_control\" value=\"yes\"> Yes<\/label>\n                  <label class=\"check-inline\"><input type=\"radio\" name=\"birth_control\" value=\"no\"> No<\/label>\n                <\/div>\n              <\/div>\n\n              <div class=\"meds-single\">\n                <span class=\"inline-label\">Is there anything else we should know about your medical history?<\/span>\n                <input type=\"text\" class=\"line-under\" id=\"medical_other\" name=\"medical_other_notes\" value=\"\" maxlength=\"500\"  \/>\n              <\/div>\n            <\/section>\n\n            <p class=\"footer-legal\">\n              I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous for my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payors and\/or health practitioners. I authorize and request my insurance company to pay directly to the dentist all insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.            <\/p>\n\n            <div class=\"signature-block\">\n              <div class=\"signature-line\">\n                <div class=\"sig-part\">\n                  <span>Patient signature, parent or guardian<\/span>\n                                    <div class=\"cf-signature-pad-wrap\" role=\"group\" aria-label=\"Draw your signature\">\n                    <canvas id=\"cf-signature-pad\" width=\"600\" height=\"160\" aria-label=\"Signature drawing area\"><\/canvas>\n                    <button type=\"button\" class=\"cf-signature-clear\" id=\"cf-signature-clear\">Clear<\/button>\n                  <\/div>\n                  <input type=\"hidden\" name=\"patient_signature\" id=\"cf-signature-data\" value=\"\" \/>\n                                  <\/div>\n                <div class=\"date-part\">\n                  <span>Date<\/span>\n                  <input type=\"text\" class=\"line-under\" id=\"signature_date\" name=\"signature_date\" value=\"\" maxlength=\"32\"  \/>\n                <\/div>\n              <\/div>\n            <\/div>\n\n            <div class=\"actions\">\n              <button type=\"submit\" class=\"submit-btn\">Submit<\/button>\n            <\/div>\n\t\t\t\t<\/form>\n\t\t\t\t<\/div>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>DEAN J. KOKINIAS, D.D.S. Patient Registration and Health History<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"site-sidebar-layout":"no-sidebar","site-content-layout":"","ast-site-content-layout":"full-width-container","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"disabled","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"class_list":["post-2199","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/project1.1stopwebsitesolution.com\/kokiniasdental\/wp-json\/wp\/v2\/pages\/2199","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/project1.1stopwebsitesolution.com\/kokiniasdental\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/project1.1stopwebsitesolution.com\/kokiniasdental\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/project1.1stopwebsitesolution.com\/kokiniasdental\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/project1.1stopwebsitesolution.com\/kokiniasdental\/wp-json\/wp\/v2\/comments?post=2199"}],"version-history":[{"count":19,"href":"https:\/\/project1.1stopwebsitesolution.com\/kokiniasdental\/wp-json\/wp\/v2\/pages\/2199\/revisions"}],"predecessor-version":[{"id":3159,"href":"https:\/\/project1.1stopwebsitesolution.com\/kokiniasdental\/wp-json\/wp\/v2\/pages\/2199\/revisions\/3159"}],"wp:attachment":[{"href":"https:\/\/project1.1stopwebsitesolution.com\/kokiniasdental\/wp-json\/wp\/v2\/media?parent=2199"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}