Your Privacy: Information transmitted from this page is encrypted and secure. Your data will never be used by anyone other than your healthcare provider.
Patient Sign-in

Patient Registration

Carol Stream Dental Associates

784 Army Trail Rd,
Carol Stream, IL, 60188
(630) 289-8899

Patient Details( * mandatory to fill )
Contact Information( * mandatory to fill )
  •  Family/Friend
  •  Walked/Passed by
  •  Insurance Company
  •  Yellow Pages
  •  Online search
  •  Other
( * mandatory to fill )
  •  Yes
  •  No
Insurance Information( * mandatory to fill )

 

INSURANCE INFORMATION (Primary Insurance)

 

INSURANCE INFORMATION (Secondary Insurance)

 

 

RESPONSIBLE PARTY( * mandatory to fill )

 

 

 

 

If the responsible party is not present, the patient automatically becomes responsible and must sign, if the patient is a minor, the mother or father of the patient is automatically responsible and must sign.

(Please click below to draw/upload sign)
(Your IP Address : IP:54.226.58.177 )

 

 

HIPPA Form ( * mandatory to fill )

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

TO THE PATIENT—PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY.

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.

 Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation and that we may decline to treat you or to continue treating you if you revoke this Consent.

Emailing x-rays

In providing the best treatment for our patients, it might be necessary to email x-rays to other specialists or dentists. I understand that x-rays might need to be emailed to other specialists and dentists. I give my permission for this service.

Disclosures

 I do hereby grant permission for Carol Stream Dental Associates and/or Elgin Dental Associates to disclose my personal health information to the following personal representative(s): (spouse, sibling, parent, child, friend, etc.)

  •  Do not disclose my personal health information with anyone other than myself.

SIGNATURES 

 I have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities, and health care operations.

If this Consent is signed by a personal representative on behalf of the patient, complete the following

(Please click below to draw/upload sign)
(Your IP Address : IP:54.226.58.177 )
HEALTH HISTORY( * mandatory to fill )
  •  Yes
  •  No
  •  Yes
  •  No

3. Date of your last physical exam 

  •  Yes
  •  No
  •  Yes
  •  No

6. DO YOU HAVE OR HAVE YOU EVER HAD 

  •  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

7. ARE YOU USING ANY OF THE FOLLOWING

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

8. ARE YOU ALLERGIC OR HAVE YOU HAD AN ADVERSE REACTION TO

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

15. Please list any and all Medications taken, including Prescription Medication, over the counter medications, herbal or holistic remedies, vitamins or minerals: (if not enough space please use back of this form to list all that you are taking): 

  •  Yes
  •  No

WOMEN ONLY 

  •  Yes
  •  No
  •  Yes
  •  No

If You are using oral contraceptives, it is important that you understand that antibiotics (and other medications) may interfere with the effectiveness of oral contraceptives. Please consult with your physician for further guidance. 

  •  Yes
  •  No

certify that the information given on this form is accurate. I understand the importance of a truthful Health History and that my dentist and his/her staff will rely on this information for treating me. I have had the opportunity to discuss my Health History with my doctor. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form. 

(Please click below to draw/upload sign)
(Your IP Address : IP:54.226.58.177 )

Disclaimer: I agree to electronically sign the document, electronic signatures processed on the document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility under the terms and conditions of the E-sign legal consent notice. 

FINANCIAL POLICY( * mandatory to fill )

 

Please read carefully and sign to acknowledge understanding and agreement

 

Thank you for choosing us as you 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, 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 notice to cancel your appointment in the case of an emergency. 
    We reserve the right to charge a fee, for those not giving notice.

Collections

  • A charge 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 attorneys fees, interest and late fees.

X-Rays.

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

 

I hereby authorize payment to

by the group insurance, otherwise payable to me.

(Please click below to draw/upload sign)
(Your IP Address : IP:54.226.58.177 )

 

 

For Office Use only( * mandatory to fill )

Please leave this page for the office use and submit the form

(Please click below to draw/upload sign)
(Your IP Address : IP:54.226.58.177 )
Copyright ©2019 SRS Web Solutions
Your browser doesn't support signing