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Patient Registration Form

Oak Creek Dental Care

6865 Oak Creek Drive Columbus, OH 43229,
Columbus, OH, 43229
6146828349

Patient Details( * mandatory to fill )
Contact Information( * mandatory to fill )
  •  Yes
  •  No
  •  Email Reminder
  •  Text Reminder
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  •  Yes
  •  No
  •  Yes
  •  No
Primary Insurance Information( * mandatory to fill )
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Secondary Insurance Information( * mandatory to fill )
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Medical History( * mandatory to fill )

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
Allergy List( * mandatory to fill )
  •  Pregnant
  •  Nursing
  •  Taking birth control
  •  Tobacco use
  •  Use or abuse recreational drugs

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.

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Broken Appointment Policy( * mandatory to fill )

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.

I,

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.

I,

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

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