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Patient Registration Form

Sharpe Dental Studio

531 Harkle Rd. Suite D,
Santa Fe, NM, 87505
(505) 982-4686

Patient Details( * mandatory to fill )
  •  Email
  •  Phone
  •  Both
Responsible Party's Information( * mandatory to fill )

EMERGENCY CONTACT INFORMATION

Primary Insurance Details( * mandatory to fill )
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Dental History( * mandatory to fill )
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

What is the goal you have for your

  •  Orthodontic treatment
  •  Periodontal treatment
  •  TMD treatment
  •  Root Canal treatment
  •  Bite adjustment
  •  Serious injury to mouth or head
  •  Do your gums bleed or hurt?
  •  Have your parents experienced gum disease or tooth lose?
  •  Have you noticed any loose teeth or change in your bite?
  •  Does food tend to get caught in between your teeth?
  •  Do you smoke / chew tobacco?
  •  Do you mouth breathe while awake or sleep?
  •  Have you noticed any mouth odors or bad taste?
  •  Clicking or popping of the jaw?
  •  Jaw Pain? (joint, ear, side of face)
  •  Pain in head, neck, shoulders, or back?
  •  Difficulty in opening or closing your mouth?
  •  Tired jaws, especially in the morning?
  •  Clenching or grinding your teeth while awake or sleep?
  •  Do you chew gum often? Sensitive teeth to cold, hot, sweets, biting, or chewing?
  •  Frequent cold sores, blisters, or any other lesion?
  •  Unsightly Restorations
  •  Missing Teeth
  •  Tooth Shape
  •  Tooth Color
  •  Bite
  •  Smile

How often do you 

Medical History( * mandatory to fill )
  •  Yes
  •  No
  •  Good
  •  Fair
  •  Poor
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

Conditions

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Aspirin
  •  Codeine
  •  Dental Anesthetics
  •  Erythromycin
  •  Jewelry
  •  Latex
  •  Metals
  •  Penicillin
  •  Tetracycline

If Female, Please Answer

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

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. 

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HIPAA Form( * mandatory to fill )

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a "friendly" version. A more complete text is posted in the office.

What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov

We have adopted the following policies:

  1. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient's condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff . You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information.
  2. It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.
  3. The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.
  4. You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties.
  5. You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor.
  6. Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services.
  7. We agree to provide patients with access to their records in accordance with state and federal laws.
  8. We may change, add, delete or modify any of these provisions to better serve the needs of the both the practice and the patient.
  9. You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.

 

I, 

on this date  

do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM and any subsequent changes in office policy. I understand that this consent shall remain in force from this time forward.

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Financial Policy( * mandatory to fill )

Please read carefully and sign to acknowledge understanding and agreement

Thank you for choosing us as you dental care provider. We are committed to providing you with the best dental care available.

Available Payment Options.

You can choose from ~ Cash, Check, Visa, Mastercard, American Express

We offer a 5% courtesy adjustment to patients who pay for their treatment, at the time of Scheduling your next appointment.

CareCredit payment plan option, ask us for detailed information.

Regarding Insurance.

  • For covered services, we ask that all co-pays and deductibles be paid on the day of treatment. Since your insurance company may not cover all costs, we ask that you pay any percentage of your balance not paid by your insurance on the day of treatment.
  • For services that are not covered by your insurance, we ask that you pay the entire fee the day of your treatment.
  • We will attempt to answer any questions we can about your insurance and, when possible We will assist in resolving complications with your insurance company. Please understand that We cannot Speak on their behalf. Your insurance contract is an agreement between you, your employer and your insurance carrier. In the event that your insurance company has not paid (on your behalf), you will be responsible to pay your account.

Patients Without Insurance.

  • For those patients without insurance coverage, you will be responsible for payment on the day of treatment. If you are not able to pay in full, or if your treatment requires several visits, you will be given an estimate and will be able to discuss payment arrangements with a member of our business office Staff.

Cancellation/No Show Policy.

  • Our office requires notice to cancel your appointment in the case of an emergency.
    We reserve the right to charge a fee, for those not giving notice.

Collections

  • A charge will be added to your account for any returned checks. You are responsible to pay all costs of collecting, or attempting to collect any debt owed on this account. This includes all attorneys fees, interest and late fees.

X-Rays.

  • You are responsible to pay a fee for duplicate copies of your X-rays.

I hereby authorize payment to

by the group insurance, otherwise payable to me.

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