Patient Registration Form Patient Details

1/3

Patient Registration Form Contact Information

1/3

Patient Registration Form Emergency Contact Information

1/3

Patient Registration Form Responsible Party

1/3

Patient Registration Form Primary Dental Insurance

1/3

Patient Registration Form Secondary Dental Insurance

1/3

Insurance is a contract between you and your insurance company. We are not a party to this contract. We may file claims as a courtesy to our patients. It is your responsibility to know and understand your policy as well as your benefits. We will not become involved in disputes between you and your insurance company regarding deductibles, co-payments, covered charges, secondary insurance, "usual and customary" charges, etc., other than to supply factual information. If your insurance company has not paid the full balance within 45 days, the responsibility for full payment will be yours.

I acknowledge having received a copy of the Practice Notice of Privacy Practices. I agree that a photocopy of this authorization is as valid as the original.

(Please click below to draw/upload sign)
(Your IP Address : IP:3.230.1.126 )

Patient Registration Form Medical History

1/3

Do you have a history of:

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

Medical Questions

  •  Yes
  •  No
  •  Local anesthetics
  •  Aspirin
  •  Penicillin
  •  Other antibiotics
  •  Barbituates, sedatives or sleeping pills
  •  Sulfa Drugs
  •  Codeine or other narcotics
  •  Metals
  •  Latex
  •  Animals
  •  Hay Fever or Seasonal
  •  Food
  •  Other
  •  Pain Medication
  •  Simvastatin
  •  Lisinopril
  •  Levothyroxine
  •  Azithromycin
  •  Metformin
  •  Lipitor
  •  Amoxicillin
  •  Amlodopine
  •  Hydrochlorothiazide
  •  Blood thinner
  •  Other
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
(Please click below to draw/upload sign)
(Your IP Address : IP:3.230.1.126 )

Patient Registration Form Dental History

1/3
  •  Comprehensive Exam
  •  Cosmetic / Esthetic Consultation
  •  Emergency
  •  Cleaning
  •  Other
  •  Yes
  •  No
  •  Cold
  •  Hot
  •  Sweets
  •  Biting / Chewing
  •  Touch
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
(Please click below to draw/upload sign)
(Your IP Address : IP:3.230.1.126 )

Patient Registration Form Payment Agreement

1/3

I agree that I am responsible for all the services rendered to the Patient and that payment is due and payable to the Practice at the time services are rendered and that health, dental and accident insurance policies are an arrangement between my insurance carrier and me. I agree to pay all deductible and co-pays at the time of service (if I have dual insurance coverage, my co-pay or deductible will be based on the primary coverage). I understand that while the Practice will file claims with my insurance company on my behalf, I remain responsible to the Practice for what is not paid by my insurance company. I also understand that if the Practice cannot verify insurance benefits eligibility for me prior to treatment that I will pay in full for the services at the time they are rendered.

  •  I understand that the Practice may charge the following items

1. A fee of $25.00 for each appointment that is missed/canceled without at least 24 business hours advanced notice

2. An amount equals to $35.00, but not to exceed the maximum amount permitted by law for each returned check

3. A late fee if payment on my account is not received by the due date.

(Please click below to draw/upload sign)
(Your IP Address : IP:3.230.1.126 )

Patient Registration Form Clinical Photography and Social Media

1/3

Consent for Clinical Photography And Authorization to Release to Media 

Please read carefully and ask questions about any areas that are unclear.

I,

authorize the team at Carolinas Dentist to take photographs and/or videos of my face, jaws and teeth, before, during, and after treatment. I consent to allow Carolinas Dentist to use these clinical photos/videos alongside protected health information in the following:

* Dental Records, including before and afters

* Dental Research

* Dental Education, including lectures, seminars, demonstrations, journals, or books

* Marketing material, including websites and printed materials, patient education, in-office streaming, and social media (Instagram, Facebook)

I further understand that if the photographs and/or videos are used, my name or other identifying information will be kept confidential. I do not expect compensation, financial or otherwise, for the use of these photographs.

Patient Rights:

1. I have the right to revoke this authorization at any time.

2. I may inspect or copy the protected health information to be disclosed as described in this document.

3. Revocation is not effective in cases where the information has already been disclosed but will be effective going forward.

4. Information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law.

5. I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing.

This authorization will remain in effect until I revoke it in writing.

(Please click below to draw/upload sign)
(Your IP Address : IP:3.230.1.126 )

Patient Registration Form Compound Authorization for Release of Information

1/3

Carolinas Dentist is authorized to release protected health information about the above named patient to the entities named below. The purpose is to inform the patient or others in keeping with the patient instructions.

Entity to Receive Information.

Check each person/entity that you approve to receive information

  •  Home Phone
  •  Work Phone
  •  Cell Phone
  •  Give information to employer
  •  Give information to school
  •  Spouse
  •  Parent
  •  Other
  •  Email

Description of information to be released

Check each that can be given to person/entity on the left in the same section.

  •  Results of lab tests/x-rays
  •  Appointment information
  •  Other
  •  Appointment absentee information
  •  Appointment absentee information
  •  Family billing information
  •  Financial
  •  Medical as follows

Rights of the Patient

I understand that I have the right to revoke this authorization at any time and that I have the right to inspect or copy the protected health information to be disclosed as described in this document by sending a written notification to CarolinasDentist.com. I understand that a revocation is not effective in cases where the information has already been disclosed but will be effective going forward.

I understand that information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law.

I understand that I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing. This authorization shall be in effect until revoked by the patient.

(Please click below to draw/upload sign)
(Your IP Address : IP:3.230.1.126 )

Preview