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Patient Registration Form - Old

New Richmond Dental

1367 Campus Drive,
New Richmond, WI 54017
(715) 246-2227

PATIENT INFORMATION CONFIDENTIAL( * mandatory to fill )

Text/email reminders are for appointment purposes ONLY. We respect your privacy and will never send your information to a third party.

Emergency Contact Information

I certify that I, and/or my dependent(s) have insurance coverage and assign directly to this dental office all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

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RESPONSIBLE PARTY'S INFORMATION( * mandatory to fill )
Dental History( * mandatory to fill )
  •  Sensitivity (hot, cold, sweet, sour)
  •  Tooth pain or discomfort
  •  Headaches, earaches, neck pain
  •  Jaw joint pain or difficulty opening/closing
  •  Grinding or clenching teeth
  •  Bleeding, swollen or irritated gums
  •  Loose, tipped or shifting teeth
  •  Bad breath or bad taste in your mouth
  •  Lumps, sores in or near mouth
  •  Food catches in teeth
  •  Dentures
  •  Partial Dentures
  •  Braces
  •  Periodontal (gum) treatments
  •  Difficult extractions or prolonged bleeding
  •  Make teeth brighter/whiter
  •  Make teeth straighter
  •  Repair chipped teeth
  •  Replace missing teeth
  •  Close spaces
  •  Replace metal fillings with tooth-colored fillings
  •  Replace old crowns that don't match
  •  Have a smile makeover

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I certify that I, and/or my dependent(s) have insurance coverage and assign directly to this dental office all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

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(Your IP Address : IP:3.226.122.74 )
Medical History( * mandatory to fill )

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
  •  Pregnant/trying to get pregnant?
  •  Nursing?
  •  Taking oral contraceptives?
  •  Aspirin
  •  Pencillin
  •  Codeine
  •  Acrylic
  •  metal
  •  Latex
  •  sulfa drugs
  •  Local anesthetics
  •  Other

Do you have, or have you had, any of the following?

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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 patients) health. It is my responsibility to inform the dental office of any changes in medical status.

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Hipaa Form( * mandatory to fill )

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:

* Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment); Continuity of care.

* Obtaining payment from third party payers (e.g. my insurance company)

* The day-to-day healthcare operations of our practice.

* Electronic Communications used for appointment notifications, patient communications, practice promotion and any requested information on your behalf. 

I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.

I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction. Please list any person(s) you would like involved in your care or payment for your care.

This consent will continue forever unless I cancel it by writing to: New Richmond Dental, 1367 Campus Drive, New Richmond, WI 54017 if the consent is cancelled, it will not change releases that have already been made prior to the date of cancellation. I don't want the consent to never expire, please expire the consent as of: 

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