Patient Registration Form Patient Details

Patient Registration Form Contact Information

Patient Registration Form Referral

Patient Registration Form Emergency Contact Information

Patient Registration Form Primary Insurance Details

Patient Registration Form Medication List

Patient Registration Form Allergy List

  •  Acrylic
  •  Aspirin
  •  Codeine
  •  Latex
  •  Local anesthetics
  •  Metal
  •  Penicillin
  •  Sulfa drugs
  •  Other
  •  None

Patient Registration Form DENTAL & GENERAL HEALTH HISTORY

  •  Yes
  •  No

If yes:

  •  None
  •  Nightguard
  •  Occusal appliance
  •  Orthotics
  •  I am still wearing a device

Patient Registration Form SUBSTANCES & CONDITIONS

 

Do any of the following conditions apply (mark all that apply):

  •  Daily
  •  Weekly
  •  Occasionally
  •  Daily
  •  Weekly
  •  Occasionally
  •  Day
  •  Week
  •  Month
  •  Day
  •  Week
  •  Month
  •  Daily
  •  Weekly
  •  Occasionally

CONDITIONS: Please mark all that apply

  •  (Men) Prostate disorders
  •  (Women) Pregnant
  •  (Women) Taking birth control
  •  Acid reflux
  •  Antidepressant medications
  •  Arthritis
  •  Artificial Prosthesis/heartvalve/joints
  •  Chemotherapy
  •  Consume grapefruit juice
  •  Contact lenses
  •  Diabetes
  •  Digestive disorders
  •  Emotional problems
  •  Epilepsy or convulsions (seizures)
  •  Family history of snoring or sleep apnea
  •  Glaucoma
  •  Have trouble getting numb before dental treatment
  •  Head or neck injuries
  •  Heart murmur
  •  Heart problems
  •  High or Low blood pressure
  •  History of a stroke
  •  Hives, skin rash, hay fever
  •  Jaundice
  •  Kidney disease
  •  Liver disease
  •  Lumps or swelling in the mouth
  •  Negative reaction to local anesthesia
  •  Often exhausted or fatigued
  •  Often unhappy/depressed
  •  Prolonged bleeding due to cut
  •  Psychiatric treatment
  •  Radiation therapy
  •  Recent changes in your health
  •  Rheumatic fever
  •  Sinus problems
  •  Subject to frequent headache
  •  Rheumatic fever
  •  Swelling in ankles or feet
  •  Tuberculosis
  •  Tumor or abnormal growth

Patient Registration Form WRITTEN RESPONSE

Patient Registration Form MULTIPLE CHOICE

  •  Waiting Room
  •  Dental Chair
  •  When scheduling
  •  When discussing costs
  •  3 Months
  •  4 Months
  •  6 Months
  •  12 Months
  •  Longer
  •  My Dentist
  •  My Self
  •  Brushing
  •  Flossing
  •  Randomly
  •  I've had periodontal treatment.
  •  Unpleasant taste in mouth
  •  Unpleasant smell in mouth
  •  Orthodontic treatment
  •  Night guard or occlusal appliance
  •  Am still wearing a device
  •  Orthotic

Patient Registration Form AREA-SPECIFIC SYMPTOMS

If you have any of the following symptoms, please select yes (Y), no (N) or sometimes (S)

 

HEAD/FACE ACHES

  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S

 

JAW

  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S

 

NECK

  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S

 

EAR

  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S

 

EYES

  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S

 

THROAT

  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S

 

MOUTH

  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S

 

NASAL

  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S

Patient Registration Form CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

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. You may obtain a copy of our Notice of Privacy Practices, including any revisions of our notice, at any time by contacting our office at (212)452-3344.

  •  Self
  •  Guradian

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 heath care operations.

 

I have received NYC Smile Design's notice of privacy practices

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Patient Registration Form Sleep Study Form

SLEEP HISTORY  Mark all that apply to you:

  •  You have had a sleep lab study
  •  You have been diagnosed with a sleep disorder
  •  You are currently using a CPAP machine
  •  You are a CPAP less than five times a week machine
  •  You would prefer an oral appliance

Note: If you have been diagnosed with a sleep disorder, please skip the sections below

PATIENT SLEEPINESS SCALE

Step 1: Answer "Yes" or "No" for the following questions (Y or N). If you answer "Yes", also circle the corresponding points in the column to the right.

Step 2: Total the points you circled in the right column and record the score in the space below.

 

QUESTIONS

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  B (BMI): Your body mass index is greater than 28
  •  A (Age): You are 50 years old or older
  •  N (Neck): You are a male with a neck circumference greater than 17 inches or a female with a neck circumference greater than 16 inches.
  •  G (Gender): You are a male

The more criteria you mark on the BANG portion, the greater your risk of having moderate to severe Obstructive Sleep Apnea.

 

DROWSINESS How likely are you to doze off or fall asleep in the following situations?

  •  0
  •  1
  •  2
  •  3
  •  0
  •  1
  •  2
  •  3
  •  0
  •  1
  •  2
  •  3
  •  0
  •  1
  •  2
  •  3
  •  0
  •  1
  •  2
  •  3
  •  0
  •  1
  •  2
  •  3
  •  0
  •  1
  •  2
  •  3

The information indicated above is truthful and accurate to the best of my knowledge.

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