Patient Registration Form Patient Details

Patient Registration Form Contact Information

  •  Email
  •  Text Message
  •  Both
  •  Patient
  •  Policy Holder
  •  Responsible Party

Patient Registration Form Responsible Party's Information

Patient Registration Form Insurance Information

Primary Insurance

Secondary Insurance

AUTHORIZATION FOR RELEASE OF IDENTIFYING HEALTH INFORMATION AND ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES.

I authorize the professional office of my dentist to release all health information identifying me to the following recipients only:

1) My primary care physician, and/ or medical/dental specialists, to aid in the diagnosis or treatment of my medical or dental health.

2) My insurance company, to allow for payment of any claims made by this office toward my dental care. I assign all insurance benefits, otherwise payable to me, to the treating doctor for services rendered. I authorize the use of the signature below on all insurance submissions.

 

I have read and understand the above form. I am signing it voluntarily. I authorize the disclosure of my health information as described in this form. I also acknowledge that I have received a copy of this office's Notice of Privacy Practices.

If you are signing as a representative of the patient, describe your relationship to the patient and the source of your authority to sign this form.

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Patient Registration Form Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

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  •  No
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  •  No
  •  Aspirin
  •  Acrylic
  •  Latex
  •  Penicillin
  •  Codeine
  •  Metal
  •  Local Anesthetics
  •  Other

Women are you

  •  Yes
  •  No
  •  Yes
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  •  Yes
  •  No

Health History:

Do you currently have, or have you ever had any of the following conditions?

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To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

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Patient Registration Form dental history

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

What is the goal you have for your

  •  Yes
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Check any that apply

  •  Yes
  •  No
  •  Yes
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Have you experienced:

  •  Yes
  •  No
  •  Yes
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  •  Yes
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  •  No
  •  Unsightly restorations
  •  Missing teeth
  •  Tooth shape
  •  Tooth color
  •  Bite
  •  Smile

How often do you

  •  Yes
  •  No
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Patient Registration Form FINANCIAL POLICY


Please read carefully and sign to acknowledge understanding and agreement

Thank you for choosing us as your dental care provider. We are committed to providing you with the best dental care available.

Available Payment Options:

You can choose from - Cash, Check, Visa, Mastercard, American Express We offer a 5% courtesy adjustment to patients who pay for their treatment, of $1000 or more, at the time of scheduling your next appointment.

CareCredit payment plan option, ask us for detailed information.

Regarding Insurance:

 

  • For covered services, we ask that all co-pays and deductibles be paid on the day of treatment. Since your insurance company may not cover all costs, we ask that you pay any percentage of your balance not paid by your insurance on the day of treatment.

  • For services that are not covered by your insurance, we ask that you pay the entire fee the day of your treatment.

  • We will attempt to answer any questions we can about your insurance and, when possible we will assist in resolving complications with your insurance company. Please understand that we cannot speak on their behalf. Your insurance contract is an agreement between you, your employer and your insurance carrier. In the event that your insurance company has not paid (on your behalf), you will be responsible to pay your account.

Patients Without Insurance:

  • For those patients without insurance coverage, you will be responsible for payment on the day of treatment. If you are not able to pay in full, or if your treatment requires several visits, you will be given an estimate and will be able to discuss payment arrangements with a member of our business office staff.

 

 Cancellation/No Show Policy:

  • Our office requires 48 hours notice to cancel your appointment in the case of an emergency. We reserve the right to charge a fee, of $50, for those not giving 48 hours notice.

Collections

 

  • A charge of $25 will be added to your account for any returned checks. You are responsible to pay all costs of collecting, or attempting to collect any debt owed on this account. This includes all attorney's fees, interest, and late fees.

X-Rays:

  • You are responsible to pay a $20 fee for duplicate copies of your x-rays.

 

 I hereby authorize payment to Bruggeman Dental by the group insurance, otherwise payable to me.

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