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New Patient Registration Form


Thank you for visiting our office.  We want your visit to be pleasant and comfortable. Please help us by completing this form.

All of this information is completely confidential.

Patient Information

Full Name (Last, First, Initial):  
Preferred Name:
Address:
City ,State, Zip: ,
   
Phones: Home-   Work-   Cell-
E-mail Address:
Soc Sec #:
Sex:
MaleFemale
Date of Birth:
Marital Status:
SingleMarriedWidowedSeparatedDivorced
Patient Employer/Occupation:
Emergency Contact:
Spouse's Name:
Spouse's Employer/Occupation:
How did you hear about our office?

Responsible Party Information

Person Financially Responsible:
Relation to patient:
   
Address:
City ,State, Zip: ,
   
Phones: Home-   Work-
Employer:
Soc Sec #:
Date of Birth:
 

Dental Insurance Information

Is patient covered by dental insurance?
YesNo
(If yes, please complete the following:)  
Policy Holder Name:
Relation to Patient:
Address:
City ,State, Zip: ,
Phones: Home-   Work-
Soc Sec #:
Date of Birth:
Insurance Company Name:
Insurance Company Phone:
Group #:
Subscriber ID#:
   
Is patient covered by additional dental insurance?
YesNo
(If yes, please complete the following:)  
   
Policy Holder Name:
Relation to Patient:
Address:
City ,State, Zip: ,
Phones: Home-   Work-
Employer:
Soc Sec #:
Date of Birth:
Insurance Company Name:
Insurance Company Phone:
Group #:
Subscriber ID#:

INSURANCE INFORMATION & FINANCIAL GUIDELINES

 

It is our desire to make necessary treatment affordable to you. Please read all information and acknowledge by signing below.

As a courtesy to you, we will gladly file the patient's primary insurance claims for services rendered. Please furnish all information necessary to submit your claim. Please keep us informed of any changes to your policy.

It is imperative that the patient understands that we cannot make a totally accurate estimate of the insurance benefits. The insurance is a contract between you and your carrier. Any deductible, co-payment, or service not covered by your insurance carrier will be your responsibility and will be due when services are rendered. Rejection of the patients claim by their carrier does not relieve you of your financial obligation in our office. If your insurance denies our charges, or does not pay us in a timely manner, or if your account becomes delinquent, we reserve the right to refer your account to a collection agency and to be reported to the credit bureau.

I understand that the fee estimate listed for dental care can only be extended for a period of three months from the date of the patient examination. Any balances on your account must be paid in full before you will be seen again unless a payment arrangement has been made with billing personnel.

Returned checks will be subject to a Non-Sufficient fund fee of $35.

Rescheduling and Cancellation Guidelines

We respect your time and make every effort to remain on schedule. Please be patient if we are behind schedule, emergencies do occur. Your appointment time has been reserved especially for you. If you are late, we may not have the appropriate time to complete the procedure, therefore; we may need to reschedule your appointment to allow us the correct time to complete your dental treatment. If you feel you will not be able to keep your appointment, please give us a 24 hour notice. You will be subject to a $50.00 service charge without a 24-hour advance notice if 2 appointments are missed. If three appointments are missed, you will be dismissed from the practice for non- compliance. For appointment times over 1 hour, you will be subject to a $100 fee for every hour missed.

Agreement: I have read the above guidelines and understand my responsibility.

 
Signature (Parent/Guardian if under age 18) Relationship (if patient is under age 18) Date
 

Medical History

Patient Name:
Physician's Name:
Phone:
Date of Last Visit:
Please check the box if you have ever had any of the following:
AIDS or HIV positiveAcid Reflux/ G.E.R.DArthritis, (Supply Type in Details Below)
Artificial jointsAsthmaCancer
Chemical DependencyDiabetes, (Supply Type in Details Below)Eating disorder
EpilepsyExcessive bleedingGlaucoma
Hepatitis, (Supply Type in Details Below)Kidney problemsLiver problems or Jaundice
Lung or breathing problemsSinus troubleSmoking/chewing tobacco
StrokeSwollen neck glandsThyroid problems
Tuberculosis
Heart Problems: Allergies: Women:
Artificial valves
Congential heart defects
Heart Surgeries
High blood pressure
Infective (Bacterial) Endocarditis
Low blood pressure
Pacemaker
Other (Supply details below)

Antibiotics for dental treatment
Currently under a physician's care
Serious illnesses/hospitalizations
Aspirin
Codeine
Latex
Local anesthetic
Penicillin
Sulfa

Other Allergies: 
Are you pregnant? 
No
Yes

Due when? 
Are you nursing? 
No
Yes
Medications: Please list medications you are currently taking and why

Dental History (New Patients Only)

Checkmark if you have ever had any of the following:
Bad breath problemBiteguard / NightguardCanker sores in mouth
Cold sores on outer lipsDental anesthetic problemsExcessive gag reflex
Fear of dental careFrequent headaches, neck achesFull dentures / Partial dentures
Oral surgeryOrthodontics (braces)TMJ, jaw joint pain or treatment
Gum disease treatment
Checkmark if you currently have any of the following:
Bleeding gumsBroken tooth or fillingClenching or grinding of teeth
Clicking or popping jawDry mouthFood packing between teeth
Loose toothMouth breathingPain
Sensitivity to - heat - cold - bitingSensitivity to - sweets - pressureSores or growths in mouth
SwellingTired, sore or painful jaw jointToothache
Vague achePain around ear
Other:
Give details and location of the above checked items:
   
How often do you brush?
How often do you floss?
What type toothbrush do you use?
UltrsoftSoftMediumHardElectric
   
Reason for today's visit
Former Dentist , City/State:    Phone:
Date and reason of last dental visit:
Date of last dental X-rays:
   
What have you liked about any dental office you've been to?
What have you liked LEAST about any dental office you've been to?

TREATMENT AUTHORIZATION

I have reviewed the information on this form and it is accurate to the best of my knowledge. I authorize and give consent for the dentist and/or team of this office to perform dental services as agreed between doctor and patient and/or guardian, including the use of local anesthetic and other medication as indicated.

Signature (Parent/Guardian if under age 18) Relationship (if patient is under age 18) Date


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