Oak Creek Dental Care-Patient Registration Form

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Patient Registration Form

Oak Creek Dental Care

6865 Oak Creek Drive,
Columbus, OH 43229
(614) 882-5525

First Name*

Last Name*

Middle Initilal

Title

Preferred Name

Gender*

Family Status*

Date of Birth*

Previous Visit

Address*

City*

State*

Zip*

Social Security Number*

How did you hear about our office?

Have you been advised that you must take an antibiotic prior to dental treatment?

lf yes, please list what for?

Email Address*

Home Phone

Mobile Phone*

Work Phone

Ext

Best time to call

We now offer patient appointment reminders via text or email. Please select your preference for receiving your appointment reminders

Email Reminder
Text Reminder

Name of lnsured*

lnsured Birth Date

ID Number

Group Number

lnsured Address

City

State

Zip Code

lnsured Employer Name

Employer Address

City

State

Zip Code

lnsurance Plan Name*

lnsurance Address*

Patient relationship to insured

City*

State*

Zip Code*

Secondary Insurance*

Name of Insured*

lnsured's Birth Date

ID Number

Group Number

Insured's Address

City

State

Zip Code

lnsured's Employer Name

Employer Address

City

State

Zip Code

lnsurance Plan Name*

lnsurance Address*

City*

State*

Zip Code*

Patient's relationship to insured

Do you or have you experienced the following?

Allergies/Hayfever

Arthritis

Aspirin Allergy

Barbiturates

Clindamycin Allergy

Coumadin

Dizziness/Fainting

Excessive Bleeding

Heart Attack

Heart Murmur

HIV

Irregular Heartbeat

Kidney Disease

Local Anesthetic

Mitral valve prolapse

Organ Transplant

Penicillin Allergy

Radiation Treatment

Sedatives

Sleep Apnea

Thyroid Problems

Venereal Disease

Anemia

Artificial Joints

Asthma

Blood Disease/Disorder

Codeine Allergy

Dementia

Emphysema

Glaucoma

Heart Disease

Hepatitis

Immune Disorder

Jaundice

Latex Allergy

Low Blood Pressure

Multiple Sclerosis

Osteoporosis

Pregnancy

Respiratory Problems

Seizures

Stroke

Tuberculosis

Angina

Artificial Valve

Autism

Cancer

COPD

Diabetes

Epilepsy

Headaches/Migraines

Heart Failure

High Blood Pressure

Intestinal Problems

Joint Replacement

Liver Disease

Mental Disorders

Nervous Disorders

Pacemaker

Psychosis/Mania

Rheumatism

Sinus Problems

Sulfa Allergy

Tumors

Please select any of the following that apply

Pregnant

Nursing

Taking birth control

Tobacco use

Use or abuse recreational drugs

Please describe your current medical treatment or any other medical condition/medical allergies not listed

Please list any/all medication(s) you are taking, including non-prescription medication(s)

Please list any surgeries you have had

Known Allergies

Emergency contact name*

Phone Number*

Medical Doctor*

Phone Number*

I certify that I have read and understand the information given to me. I understand that providing incorrect information can be dangerous to my health; the questions have been accurately answered. I authorize the dentist to release any information, including diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payers and/or health practitioners. I authorize and request my insurance company to pay insurance benefits otherwise payable to me, directly to the dentist or dental group. I understand my dental insurance carrier may pay less than the actual bill of services. I agree to be responsible for payment of all services rendered on my behalf or my dependents (including broken appointment fees, late fees, collection agency, and/or attorney fees). I acknowledge that I have received and read a copy of the privacy practices and welcome policies.

SIGNATURE (Signature)*

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Broken Appointment policy

A 48 hour advance notice is requested if you are unable to keep an appointment. A charge of $61 per hour will be applied for appointments broken without a 48 hour notice.

have read and understand Oak Creek Dental Care's broken appointment policy.

Insurance

As a courtesy, Oak Creek Dental Care will file your insurance for you. The patient portion quoted to you is simply an estimate based on the information we have gathered from your insurance carrier. Oak Creek Dental Care does not accept responsibility for lack of insurance coverage or for anything your insurance does not pay.

have read and understand Oak Creek Dental Care's insurance disclaimer and understand that it is ultimately my responsibility to know my insurance benefits.

SIGNATURE (Patient Signature)*

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Please sign in the box using your mouse if you are on a computer.

CLEAR

We recommend reviewing the form to ensure the information is correct.
Click 'Preview' to review the form and then submit Click 'Submit' if you would like to submit the form without review

Patient Details( * mandatory to fill )

Contact Information( * mandatory to fill )

Primary Insurance Information( * mandatory to fill )

Secondary Insurance Information( * mandatory to fill )

Medical History( * mandatory to fill )

( * mandatory to fill )

Broken Appointment Policy( * mandatory to fill )