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 Form

North Portland Dental

1832 N. Lombard St,
Portland, OR 97217
(503) 232-3232

Patient Details( * mandatory to fill )

Welcome to our practice! Our goal is to provide the Ultimate Dental Health Experience. Please fill out this form completely so that we can provide you with the best possible care.

Contact Information( * mandatory to fill )
  •  Yes
  •  No
EMERGENCY CONTACT INFORMATION
( * mandatory to fill )
  •  Yes
  •  No
Responsible Party's Information( * mandatory to fill )
( * mandatory to fill )
  •  Yes
  •  No
Insurance Information( * mandatory to fill )

PRIMARY INSURANCE INFORMATION

SECONDARY INSURANCE INFORMATION

Attestation/Signature( * mandatory to fill )

By signing below,

* I attest that the information on this form is correct to the best of my knowledge.

* I authorize the Dentist and/or a qualified assignee to perform procedures required for examination and diagnosis, and subsequent recommended treatment. I understand that all recommendations will be discussed with me and that I will have the opportunity to accept or decline treatment.

* I grant the right to the Dental Office to release my dental/medical information to third-party payors and other health professionals when necessary.

* I authorize the use of my electronic signature on all insurance submissions.

* I authorize my insurance company to pay all insurance benefits rendered directly to this Dental Office.

* I acknowledge that I am responsible for all charges, whether or not paid by insurance.

(Please click below to draw/upload sign)
(Your IP Address : IP:34.204.173.45 )
HEALTH AND DENTAL HISTORY( * mandatory to fill )
  •  Yes
  •  No
  •  Good
  •  Fair
  •  Poor
  •  Yes
  •  No
  •  Yes
  •  No
  •  Weight control medication
  •  Dietary supplements

FOR WOMEN

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

MEDICAL ALERTS/CONDITIONS

  •  Anemia
  •  Anxiety
  •  Arthritis
  •  Artificial Heart Valve
  •  Artificial Joints
  •  Asthma
  •  Bacterial Endocarditis
  •  Bisphosphonate Therapy
  •  Blood Disease
  •  Cancer
  •  Cold Sores
  •  Coronary Stent
  •  Diabetes
  •  Dizziness
  •  Epilepsy/Seizures
  •  Epinephrine Sensitivity
  •  Excessive Bleeding
  •  Fainting
  •  Frequent Headaches
  •  Glaucoma
  •  Head/Neck Injuries
  •  Heart Attack
  •  Heart Disease
  •  Heart Murmur
  •  Hemophilia
  •  Hepatitis A or B
  •  Hepatitis C
  •  High Blood Pressure
  •  HIV+/AIDS
  •  Hypoglycemia
  •  Jaundice
  •  Kidney Disease
  •  Liver Disease
  •  Low Blood Pressure
  •  Mental Disorders
  •  Migraines
  •  Nervous Disorders
  •  Pacemaker
  •  Pulmonary Shunt
  •  Radiation Treatment
  •  Respiratory Problems
  •  Rheumatic Fever
  •  Rheumatism
  •  Sinus Problems
  •  Sleep Apnea
  •  STD/Venereal Disease
  •  Stomach Problems
  •  Stroke
  •  Thyroid Disease
  •  Tuberculosis
  •  Tumors
  •  Ulcers
  •  Yes
  •  No
  •  Yes
  •  No

DENTAL INFORMATION

  •  3 mo
  •  4 mo
  •  6 mo
  •  12 mo
  •  Not routinely
  •  Excellent
  •  Good
  •  Fair
  •  Poor
  •  Never
  •  Occasionally
  •  Once/day
  •  Twice/day
  •  More than twice/day
  •  Never
  •  Occasionally
  •  Once/day
  •  Twice/day
  •  More than twice/day
  •  Manual
  •  Electric
  •  I have had an unfavorable dental experience
  •  I have had complications from past dental treatment
  •  I have had trouble getting numb in the past
  •  I have had reactions to local anesthetic
  •  I have/have had braces (orthodontic treatment)
  •  I have had teeth removed
  •  I have had a toothache
  •  I have dry mouth
  •  I would like to change the appearance of my teeth/smile
  •  I feel uncomfortable or self-conscious about the appearance of my teeth
  •  I have a habit of hiding my teeth when I smile
  •  I am disappointed with the appearance of previous dental work
  •  I have previously whitened (bleached) my teeth
  •  My gums bleed when brushing or flossing
  •  I have been treated for gum disease
  •  I have been told I have lost bone around my teeth
  •  I have noticed an unpleasant taste or odor in my mouth
  •  I have a history of periodontal disease in my family
  •  I have receding gums
  •  I have loose teeth
  •  I have experienced a burning sensation in my mouth
  •  I have had cavities in the past 3 years
  •  I have holes, pitting, or craters on the biting surface of my teeth
  •  I have grooves or notches in my teeth
  •  I have chipped teeth or filling(s)
  •  My teeth are sensitive to hot, cold, biting, or sweets
  •  I avoid brushing any part of my mouth
  •  I get food caught between my teeth
  •  I have pain in my jaw joint(s) or jaw muscles
  •  My jaw clicks or pops
  •  I have shoulder or neck pain
  •  I carry my tension in my jaws
  •  I do not have a comfortable bite position
  •  I have had my bite adjusted
  •  I have problems chewing, or I avoid eating certain foods because my jaw gets tired
  •  I chew ice, bite my nails, use my teeth to hold objects, or have any other oral habits
  •  I have a history of clenching my teeth during the day or at night
  •  I currently clench my teeth in the daytime and/or notice them feeling sore
  •  I currently clench my teeth at night or wake up with an awareness of my teeth
  •  I regularly wake up in the morning with headaches
  •  I wear or have worn a bite appliance or night guard
  •  My teeth have changed in the last 5 years - become shorter, thinner, or worn
  •  My teeth are crowding or developing spaces
  •  I keep my tongue pressed against the roof of my mouth
  •  I snore occasionally
  •  I snore frequently
  •  I awaken frequently, or I do not sleep through the night
  •  I grind my teeth in my sleep
  •  I do not feel well-rested in the morning
  •  I often feel tired, fatigued, or sleepy during the day

ATTESTATION

I attest that the information on this form is correct to the best of my knowledge.

(Please click below to draw/upload sign)
(Your IP Address : IP:34.204.173.45 )
FINANCIAL AGREEMENT AND APPOINTMENT POLICY( * mandatory to fill )

Thank you for choosing our practice. We believe in giving you the best possible dental care and want you to feel as comfortable as possible throughout your treatment. This includes understanding your treatment options and costs, as well as our expectations regarding payment and appointment changes or cancellations.

PAYMENT EXPECTATIONS

Our practice depends upon reimbursement from the patient for costs incurred in their care. As a condition of treatment by this office, payment is due at the time of service unless other arrangements have been made. For multiple appointment procedures such as crowns, dentures, or orthodontics, we expect an initial deposit at the first appointment and final payment by the last appointment.

* Payment options: We accept cash, checks, all major credit cards, and Care Credit.

* Discounts: For uninsured patients, we offer a 5% discount for payment in full with cash or check at the time of service. For senior patients (65 and over) we offer a 5% discount for payment in full at time of service.

* Financing: For patients who are unable to pay in full at time of service, we have partnered with Care Credit to offer extended pay options up to 12 months with deferred interest. We do not offer in-house financing.

PATIENT WITH DENTAL INSURANCE

If you have a dental benefit plan through an employer or an individual plan, we will bill your plan as a courtesy and will only ask for your estimated out-of-pocket portion at time of service. It is your responsibility to provide accurate and current information about your insurance prior to your appointment. If insurance eligibility and/or benefits cannot be verified at the time of service, payment is expected in full.

Insurance coverage can be difficult to calculate due to many factors including waiting periods, deductibles, excluded services, and annual maximums. In addition, many insurance companies limit their coverage to their own set of usual, customary and reasonable (UCR) fees, which are often outdated and are seldom relevant to current, high-quality dentistry. Although we do our best to provide an accurate estimate of insurance benefits prior to the time of service, payment can never be guaranteed, even if the service is preauthorized. If, after 90 days, your insurance has not paid as expected, you will be billed for any remaining charges for treatment provided.

FINANCE CHARGES AND OTHER FEES

* To offset the costs associated with repeated billing statements, all past due balances (30 days and greater) are subject to finance charges of 18% APR (1.5% per month), or a minimum of $5/month.

* A $35 fee will be charged for any returned check.

* A $150 fee will be charged to any account turned over to a collection agency.

APPOINTMENT AND CANCELLATION POLICY

We will make every effort to accommodate your scheduling needs and keep our scheduled on time. In return, we ask that you help us by confirming your appointment in advance and arriving on time, or notifying us at least 24 business hours in advance if you are unable to keep your scheduled appointment. (If the appointment is on a Monday, please contact us by mid-day on Friday.)

Appointment time is reserved for you and you alone, and without advance notice, we are generally unable to make use of missed appointment time. Therefore, late cancellation or failure to keep an appointment will result in a fee of $55 per patient, per hour reserved. We are sensitive to the fact that emergencies do come up but ask that you do your best to keep us informed.

WARRANTY

Dr. Watson has a sincere desire to aid our patients in the event of the unexpected early failure of any dental treatment provided in our office. If the work was done at our office and you have been seen regularly for routine exams, you may qualify for a free or reduced-cost replacement depending on circumstances. All cases must first be reviewed by Dr. Watson before making the final decision of warranty coverage.

ATTESTATION

By signing below,

* I attest that I have read and fully understand the financial policies of this dental office.

* I acknowledge I am responsible for all charges for dental treatment, regardless of what my insurance may cover.

* I agree to pay my estimated portion at the time of service.

* I agree to pay promptly on any balance due and will call the office if I do not understand my bill.

* I agree to notify the practice at least 24 business hours in advance if I am unable to keep my scheduled appointment time.

(Please click below to draw/upload sign)
(Your IP Address : IP:34.204.173.45 )
Notice of Privacy Practices( * mandatory to fill )

Our practice is committed to maintaining the confidentiality of your personal financial and health information. This notice describes how information about you may be used and disclosed, and how you can get access to your information and limit its use. Please review this notice carefully.

Information we collect:

Examples of personal information we may collect include: your name, birthdate, Social Security number, state license number, address, telephone number, email address, employer, medical history, dental records, and insurance information.

Information we share:

We may share your personal information with other third parties without your prior authorization for our normal business functions, which may include:

  • Securing insurance benefit information
  • Submitting insurance claims
  • Sending billing statements
  • Communicating with specialists
  • Fulfilling requests from other health care providers or pharmacies
  • Processing transactions that you request
  • Sending appointment reminders via postcard, voice message, email, or text message

How we protect your personal information:

  • We authorize individuals to access your personal information only to the extent necessary to conduct our business of serving you.
  • We take every precaution to secure our building, patient files, and electronic systems from unauthorized access.
  • Our business associates and vendors who may have access to patient information are required to sign a confidentiality agreement.
  • Our employees are trained regarding confidentiality and are held to strict policy and procedures regarding your personal and health information both written and verbal. All employees are subject to discipline if they violate these procedures.

Our responsibilities:

  • We are required by law to maintain the privacy and security of your protected health information.
  • We must follow the duties and practices described in this notice and offer you a copy.
  • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time.
  • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

Your rights:

You have the right to:

  • Get a copy of your paper or electronic medical record
  • Correct your paper or electronic medical record
  • Request confidential communication
  • Ask us to limit the information we share
  • Get a list of those with whom we’ve shared your information
  • Get a copy of this privacy notice
  • Choose someone to act for you
  • File a complaint if you believe your privacy rights have been violated

To request a copy of your paper or electronic records, you must submit a written request describing the information you are requesting. We will provide a copy or a summary of your health information, usually within 30 days. We may charge a reasonable, cost-based fee.

If you request a correction, amendment or deletion of personal information, we will either make the requested change or notify you of our refusal within 60 days.

Changes to the terms of this notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request in our office and on our website.

ACKNOWLEDGEMENT

I acknowledge that I have seen the Notice of Privacy Practices for this dental facility, which describes the uses and disclosures of my protected health information (PHI) that might occur in my treatment, payment of my bills, or in the performance of health care operations. I agree to the terms set forth in the Notice as well as any subsequent changes in office policy, and understand that this consent shall remain in force from this time forward. I will have the opportunity to review the most current version of the Notice of Privacy Practices at any time. This Acknowledgement will be filed in my dental record.

(Please click below to draw/upload sign)
(Your IP Address : IP:34.204.173.45 )
Records Release to Dr. Watsons Office( * mandatory to fill )

RECORDS TRANSFER REQUEST

I authorize the release of my dental records to the office of Dr. Keith Watson.

(Please click below to draw/upload sign)
(Your IP Address : IP:34.204.173.45 )

Instructions to Dental Office:

Please email any images less than five (5) years old to frontoffice@northportlanddental.com. Send images in Dexis format if possible, otherwise as individual JPEG files.

In addition, please provide the dates of the following services:

* Last full mouth series or pano

* Last bitewing series

* Last periodontal charting

* Last dental exam

* Last prophy or perio maintenance

* Last SRP treatment, if applicable

Copyright ©2019
Your browser doesn't support signing