Patient Registration Form Patient Details

Patient Registration Form Contact Information

  •  Cell Phone
  •  Email
  •  Home Phone
  •  Leave a message

Employment

  •  the patient
  •  the person responsible for payment
  •  both
  •  not applicable

Patient Registration Form

Insurance Subscriber and/or Parent/Guardian Information

 

This page ONLY needs to be completed if the insurance subscriber is OTHER than the patient AND/OR you are the parent/guardian of the patient

  •  Married
  •  Single
  •  Child
  •  Other

Patient Registration Form Primary Insurance Details

  •  Self
  •  Spouse
  •  Child
  •  Other

Insurance Authorization

  •  By checking this box,

I authorize my insurance company to pay the dentist all insurance benefits rendered.
I authorize the use of this electronic signature on all insurance submissions.
I authorize the dentist to release all information necessary to secure the payment of benefits.
I understand that I am financially responsible for all charges whether or not paid by insurance.

Patient Registration Form Dental Information

  •  Excellent
  •  Good
  •  Fair
  •  Poor
  •  3 mos
  •  4 mos
  •  6 mos
  •  12 mos
  •  Not routinely

Check all that apply

  •  Had complications from past dental treatment
  •  Had trouble getting numb
  •  Had any reactions to local anesthetic
  •  Had/Have braces or orthodontic treatment
  •  Experiences dry mouth
  •  Sensitive to hot, cold, biting, sweets or avoid brushing any part of your mouth
  •  Food gets trapped between any teeth
  •  Whitened or bleached your teeth
  •  Experienced popping and/or clicking of your jaw joint
  •  Difficulty chewing
  •  Clenching or grinding of teeth
  •  Currently or previously wore a bite appliance
  •  Wears removable partial/denture
  •  Gums bleed when brushing or flossing
  •  Diagnosed and/or treated for gum disease
  •  Bone loss around your teeth
  •  Noticed an unpleasant taste or odor in your mouth
  •  Experienced gum recession
  •  Teeth become loose on their own (without injury)
  •  Experienced a burning sensation in your mouth
  •  Snores or wakes up frequently during the night

Patient Registration Form Consent for Services and Financial Policy

As a condition of treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from patients for the costs incurred in their care. Financial responsibility on the part of each patient must be determined before treatment.

All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed unless other arrangements are made.

Patients with dental insurance understand that all dental services are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patient's insurance forms or assist in making collections from insurance companies and will credit any collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.

A service charge of 1.5% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied.

I understand that any fee estimate for this dental care can only be extended for a period of six months from the date of the patient examination.

In consideration for the professional services rendered to me by this practice, I agree to pay the charges for the services at the time of treatment, or within five (5) days of billing if credit is extended. I further agree that the charges for services shall be as billed unless objected to, by me, in writing, within the time payment is due. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder.

 I grant my permission to you or your assignee, to telephone me to discuss this statement or my treatment.

  •  By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature for the AdministrationForm.

Patient Registration Form HIPAA Acknowledgment

I understand that I may inspect or copy the protected health information described by this authorization.

I understand that at any time, this authorization may be revoked, when the office that receives this authorization receives a written revocation, although that revocation will not be effective as to the disclosure of records whose release I have previously authorized, or where other action has been taken in reliance on an authorization I have signed. I understand that my health care and the payment for my healthcare will not be affected if I refuse to sign this form.

 I understand that information used or disclosed, pursuant to this authorization, could be subject to re-disclosure by the recipient and, if so, may not be subject to federal or state law protecting its confidentiality,

I authorize this dental practice to release any financial or dental information to the following person(s) listed below:

  •  By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature for the HIPAA Disclosure Form.

Patient Registration Form Consent for Internet Communications

I grant my permission to the dental practice to upload and store confidential patient information (including account information, appointment information and clinical information) to the secured web site for the dental practice. I understand that, for security purposes, the site requires a user ID and password for access and use. I also understand the dental practice and I are responsible for maintaining the strict confidentiality of any ID and password assigned to me; and that the dental practice is not liable for any charges, damages, or losses that may be incurred or suffered as a result of my failure to maintain confidentiality. I understand the dental practice is not liable for any harm related to the theft of my ID and password, my disclosure of my ID and password, or my authorization to allow another person or entity to access and use the dental practice web site with my ID and password. I also agree to immediately notify the dental practice of any unauthorized use of my ID or of any other need to deactivate my ID due to security concerns.

 I also understand that State and Federal laws, as well as ethical and licensure requirements impose obligations with respect to patient confidentiality that limit the ability to make use of certain services or to transmit certain information to third parties. I understand the dental practice will represent and warrant that they will, at all times during the terms of this Agreement and thereafter, comply with all laws directly or indirectly applicable that may now or hereafter govern the gathering, use, transmission, processing, receipt, reporting, disclosure, maintenance, and storage of my information, and use their best efforts to cause all persons or entities under their direction or control to comply with such laws. I agree that the dental practice has the right to monitor, retrieve, store, upload and use my information in connection with the operation of such services, and is acting on my behalf in uploading my patient information. I understand the dental practice will use commercially reasonable efforts to maintain the confidentiality of all patient information that is uploaded to the web site on my behalf. I understand the dental practice CANNOT AND DOES NOT ASSUME ANY RESPONSIBILITY FOR MY USE OR MISUSE OF PATIENT INFORMATION OR OTHER INFORMATION TRANSMITTED, MONITORED, STORED, UPLOADED OR RECEIVED USING THE SITE OR THE SERVICES.

  •  I have read the information above regarding the secured uploading of patient information to the web site for the dental practice, and grant the dental practice permission to securely upload my patient information to the web site.
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Patient Registration Form Medical History

Indicate which of the following you have had or have at present. By checking the box it will indicate a "Yes" response, leaving blank will indicate a "No" response.

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  •  By checking this box, I acknowledge that I have reviewed ALL questions/alerts on this questionnaire and responded accordingly. There are no other medical conditions or medications/allergies that have not been listed. I am aware that I must notify the practice of any future changes. This will serve as my electronic signature.

Patient Registration Form DISCLOSURE AND CONSENT DENTAL AND ORAL SURGERY

DISCLOSURE AND CONSENT - DENTAL AND ORAL SURGERY

TO THE PATIENT: You have the right, as a patient to be informed about your condition and about the recommended surgical, medical, or diagnostic procedures to be used so that you may make the decision whether or not to undergo the procedure after knowing the risks and hazards involved This disclosure is not meant to scare or alarm you; it is simply an effort to make you better informed so you can give or withhold your consent to the procedure

 I voluntarily request kDentistName and such associates. technical assistants, and other health care providers as they may deem necessary, to treat my condition which has been explained to me as:

If (we) understand that the following surgical, medical, and/or diagnostic procedures are planned for me (us), and I (we) voluntarily consent and authorize these procedures under local anesthesia supplemental by

  •  Oral Sedation

I (we) understand that my doctor may discover other or different conditions which require additional or different procedures than those planned. I (we) authorize my doctor and such associates, technical assistants, and other health care providers to perform such other procedures which are advisable in their professional judgment.

I (we) understand that no warranty or guarantee has been made to me as to result or cure. I (we) have been given both oral and written post-operative instructions, and I (we) agree to personally contact kDentistName in the event I (we) have a problem. I (we) will follow his instructions until that problem has been satisfactorily resolved. I (we) realize that in the event I (we) develop certain complications. I (we) may miss school or work schedules or I (we) may incur additional, unexpected expenses, including, but not limited to. expenses for other dentists, doctors or medical facilities.

 Just as there may be risks and hazards in continuing my present condition without treatment, there are also risks and hazards related to the performance of the surgical. medical, and/or diagnostic procedures planned for mo. I (we) realize that common to surgical, medical, and/or diagnostic procedures is the potential for infection, pain, swelling, bleeding, bruising, allergic reactions, and even death. I (we) also realize that the following risks and hazards may occur in connection with this particular procedure:

  •  1. Temporary or permanent nerve injury resulting in altered sensations or numbness of the lips, chin, tongue. Teeth, and/or gums.
  •  2. Damage to adjacent teeth and/or dental restorations.
  •  3. Soreness at injection sites and/or along veins. as well as discoloration of the injection sites, face, and/or C jaws.
  •  4. Opening of the sinus requiring additional treatment.
  •  5. Jaw fracture, muscle spasms, and/or limited opening of jaws for several days or weeks.
  •  6. Small root fragments remaining in the jaw due to an increased possibility of surgical complications.
  •  7. Jaw joint (TMJ) tenderness, soreness, pain, or locking, which may be temporary or permanent.
  •  8. Other
  •  1. Temporary or permanent nerve injury resulting in altered sensations or numbness of the lips, chin, tongue. Teeth, and/or gums.
  •  2. Damage to adjacent teeth and/or dental restorations.
  •  3. Soreness at injection sites and/or along veins. as well as discoloration of the injection sites, face, and/or C jaws.
  •  4. Opening of the sinus requiring additional treatment.
  •  5. Jaw fracture, muscle spasms, and/or limited opening of jaws for several days or weeks.
  •  6. Small root fragments remaining in the jaw due to an increased possibility of surgical complications.
  •  7. Jaw joint (TMJ) tenderness, soreness, pain, or locking, which may be temporary or permanent.
  •  8. Other

I (we) have been given opportunity to ask questions about my (our) condition, alternative forms of anesthesia and treatment, risks of non-treatment, the procedures to be used, and the risks and hazards involved, and I (we) believe that I (we) have sufficient information to give this consent.

 I (we) certify this form has been fully explained to me (us), that I (we) have read it or have had it read to me (us), that the blank spaces have been filled in, and that I (we) understand its contents.

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