Patient Registration Form Patient Information *All fields requiredSalutation*Mr.Mrs.Ms.Dr.First Name*Last Name*Date of Birth* MM slash DD slash YYYY Registering for a child?* Yes No Person responsible for account*Other parental consent required* Yes No Mother’s name*Business Tel*Father’s name*Business Tel*Contact InformationEmail* Home PhoneCell Phone*Work PhoneAddress* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip In case of emergency, please notify:Name*Relation*Home PhoneCell Phone*Work PhoneContact OptionsI prefer appointment reminders by* Phone SMS (TEXT) Email Whom may we thank for referring you?*Are any other members of your family patients at our practice?* Yes No Please list all family members*Insurance Information* Yes, insurance applies to me No, insurance does not apply to me Please complete the following if you have dental insuranceName of insured/subscriber*Date of Birth* MM slash DD slash YYYY Patient's relationship to subscriber* Self Spouse Child Place of Employment*Insurance Company*Policy/Group #*Member/ID # or Social Security Number*I authorize release to my dental benefits plan administrator information contained in claims and/or predeterminations* Yes Medical History The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by Doctor/Patient confidentiality. The Dentist will review the questions and explain any that you do not understand. Please complete the entire form.Are you being treated for any medical condition at the present or any time within the past year?* Yes No Not Sure/Maybe Please Specify*When was your last medical checkup?* MM slash DD slash YYYY Has there been any change in your general health in the past year?* Yes No Not Sure/Maybe Please Specify*Are you taking any prescription, non-prescription medications, or herbal supplements?* Yes No Not Sure/Maybe Please list and provide dosages. If there is insufficient room, please bring a written list of all your medications to your first appointment.Please provide the information for your preferred pharmacy.*Do you have any allergies?* Yes No Not Sure/Maybe AllergiesThis field is hidden when viewing the form--select--*MedicationsLatex/Rubber ProductsOther (e.g hayfever, foods, etc)Have you ever had a peculiar or adverse reaction to any medicines or injections?* Yes No Not Sure/Maybe Please list below with approximate dates*This field is hidden when viewing the formPlease list below with approximate dates* MM slash DD slash YYYY Do you have or have you ever had asthma?* Yes No Not Sure/Maybe Please Specify*Do you have or have you ever had any heart or blood pressure problems?* Yes No Not Sure/Maybe Please Specify*Do you have or have you ever had an artificial heart valve, infection of the heart (i.e. #infective endocarditis), a heart condition from birth (i.e. congenital heart disease), or a heart transplant?* Yes No Not Sure/Maybe Please Specify*Do you have a prosthetic or artificial joint?* Yes No Not Sure/Maybe Please Specify*Do you have any conditions which may affect your immune system (i.e. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?* Yes No Not Sure/Maybe Please specify*Have you ever had hepatitis, jaundice, or liver disease?* Yes No Not Sure/Maybe Please Specify*Do you have a bleeding problem or bleeding disorder?* Yes No Not Sure/Maybe Please specify*Have you ever been hospitalized for any illnesses or operations?* Yes No Not Sure/Maybe Please specify*Do you have, or have ever had any of the following? Please check* Chest pain/angina Osteoporosis Medications Mitral Valve Prolapse Shortness of Breath Rheumatic Fever Heart Attack Stroke Cancer Pacemaker Lung Disease Heart Murmur Arthritis Steroid Therapy Diabetes Tuberculosis Drug/Alcohol Dependency Seizures Thyroid Disease Stomach Ulcers Kidney Disease None of the above Are there any conditions/diseases not listed that you have or have had?* Yes No Not Sure/Maybe If yes, please specify:*Are there any diseases/medical problems that run in your family (e.g. diabetes, cancer, heart disease, etc.)?* Yes No Not Sure/Maybe If yes, please specify:*Do you smoke or chew tobacco products?* Yes No Not Sure/Maybe Please Specify*Are you nervous during dental treatment?* Yes No Not Sure/Maybe Please Specify*For women only: Are you pregnant or breastfeeding? Yes No Not Sure/Maybe What is your expected delivery date? MM slash DD slash YYYY Dental HistoryDo you have any specific dental concerns? Please list:*When was your last dental appointment?* MM slash DD slash YYYY How often do you see the dentist?* Not Applicable Every 3 months Every 4 months Every 6 months Only when something is bothering me Is there anything about the appearance of your teeth that you would like to change?*Do you feel uncomfortable or self-conscious about the appearance of your teeth?*Have you been disappointed with the appearance of previous dental work?Sleep HistoryDo you think you snore? Yes No Please explain:Have you had or been told to have a sleep study? Yes No Please indicate whether you completed it and in what year:Explain why:Have you been diagnosed with sleep apnea? Yes No Please indicate severity and approximate year diagnosedDo you wear a C-PAP or have you in the past? Yes No Please indicate approximately how many nights per week on average you wear it and the average number of hours. If you are not wearing it or limit your wear, please indicate why. I agree to receive emails with related information and updates. Financial Arrangement Financial Arrangement By having flexible and consistent payment arrangements, our office can focus on our specialty of providing you with superior customer service, optimal dentistry, a comfortable environment, and state of the art technology while keeping our fees as low as possible. Payment Options/Savings Opportunities Please check below each financial option you would like to discuss with our financial coordinator or that you feel applies to you: Military Valor Discount: A 10% courtesy discount is given to families currently in the armed forces and individuals with prior service record. This discount is reduced to 7.5% when using credit cards and 5% when financing to offset our costs. Prepayment Discount: A 5% courtesy discount is given when entire cases are prepaid by check, in full, as arranged by our financial coordinator. True No-Interest Financing: Pay over 6 or 12 months with no interest. Extended Financing: Low monthly payments ranging from 24-84 months, with interest. Credit Card/Debit/Check: Date of service payments. UntitledTreatment Fee Estimates and Insurance Coverage We will always make every effort to explain all anticipated fees in advance. Two primary variables are out of our control; complexity of oral conditions and insurance reimbursements. Treatment costs can change during procedures and will be counseled when faced. If you have dental benefits, we will estimate your out of pocket costs and payment will be due at time of serviceUntitledAppointments, Timeliness, and Communications We are committed to seeing you on-time for your reserved appointment and request that you arrive on-time for your visits as well. We expect at least 1 business day notice be given if an appointment needs to be rescheduled. You will incur a fee of $50/hour reserved if insufficient notice is given. Please, feel free to contact us if you have any questions or concerns regarding your dental treatment or financial arrangements. It is our pleasure to serve you as our patient and we want you to have any and all financial questions clarified.UntitledCredit Card Convenience In order to streamline our billing processes, we will reserve a credit card on file using our secure server. This card will be used in two circumstances: Credit Refund: If a credit due to overpayment is on your account, we will process a refund to bring your balance with us to zero. Debit Charge: If a balance remains after insurance payment, we will process a debit from your card to resolve your balance. Any charges above $250 will be verified via phone before processed. Please have card ending in (last 4 digits)and expiring on (fill in the space provided) ready for our financial coordinator to file on our secure server. Yes, I consent No, I Opt Out UntitledCertification I certify that I have read and understand the above information to the best of my knowledge. My health history questionnaire has been accurately answered. I understand that providing incorrect information can be dangerous to 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 dependent during the period of such dental care to third part payors and /or health practitioners. I authorize and request my dental benefit company (and medical insurance if applicable) to pay directly to the dentist unless otherwise specified. I understand that my dental benefits will not cover 100% of all dental expenses. I agree to be responsible for payment of all services rendered on my behalf or my dependents that are not covered by my dental/medical benefits. Patient Name (Print)Responsible Party (Print, If Applicable)SignatureDate MM slash DD slash YYYY ACKNOWLEDGEMENT Of RECEIPT OF NOTICE OF PRIVACY PRACTICES “You May Refuse to Sign This Acknowledgement” I have received a copy of this offices Notice of Privacy Practices. PATIENT CONSENT I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I have certain right to privacy regarding my protected health information. I understand that this information can and will be used to: Conduct, Plan and direct my treatment and follow-up among the healthcare providers Obtain payment form third-party payers. Conduct normal healthcare operations such as quality assessments and physician certification. I have been informed by you and your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy prior to signing this consent. I understand that I may contact this organization at any time to obtain a copy of Privacy Practices. I Understand I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or health care operations. I also understand that you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent. The following individual or company has the right to receive my information: Name:Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Company (if applicable):Contact NumberRelationship to Patient:The following individual or company does NOT have the right to receive my information:NameCompanySignatureDate MM slash DD slash YYYY CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
