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Patient Registration Form

Smile Pro Studio

1701 E. Woodfield RD # 510,
Schaumburg, IL 60173
(847) 850-0254

Patient Details( * mandatory to fill )
Contact Information( * mandatory to fill )
Emergency Contact Information( * mandatory to fill )
Responsible Party's Information( * mandatory to fill )
Primary InsuranceDetails( * mandatory to fill )
Medical History( * mandatory to fill )

Although dental care primarily treats the area in and around your mouth, you cannot separate it from the rest of your body. Health problems that you may have and medications that you are taking could have an important interrelationship with the dental care you will receive. Please be thorough and truthful in answering the following questions. If additional space is needed, please continue on a separate sheet and check here

  •  I have continued my health information on a separate sheet.
  •  Yes
  •  No
  •  Yes
  •  No
  •  my primary doctor
  •  a specialist
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  I have provided a printed list.
  •  I do not take any medications

Please list over the counter medications or supplements that you take on a regular basis

  •  I do not take any
MEDICAL HISTORY( * mandatory to fill )

Medications and Conditions that can complicate dental care

Pre-Med

  •  Yes
  •  No
  •  I don't know
  •  Joint replacement
  •  Heart valve surgery or heart transplant
  •  History of infective endocarditis or congenital heart defect
  •  Amoxicillin
  •  Clindamycin/Cleocin
  •  Other
Blood Thinners: Please select any of the following blood thinning medications that you are currently taking
  •  Fish oil
  •  Co-Q10
  •  Motrin
  •  Aspirin/Ecotrin
  •  Warfarin (Coumadin)
  •  Dabigatran (Pradaxa)
  •  Apixaban (Eliquis)
  •  Rivaroxaban (Xarelto)
  •  Heparin (various)
  •  Dabigatran (Pradaxa)
  •  Edoxaban (Savaysa)
  •  Plavix (Clopidogrel)
  •  Prasugrel
  •  Brilinta
  •  Cilostazol
  •  Aggrenox
  •  Other
  •  I do not take any blood thinners
Bone Density Medications: Please select any of the following bone density medications that you are currently taking
  •  Aspirin/Ecotrin
  •  Warfarin (Coumadin)
  •  Dabigatran (Pradaxa)
  •  Apixaban (Eliquis)
  •  Rivaroxaban (Xarelto)
  •  Heparin (various)
  •  Dabigatran (Pradaxa)
  •  Edoxaban (Savaysa)
  •  Plavix (Clopidogrel)
  •  Prasugrel
  •  Brilinta
  •  Cilostazol
  •  Aggrenox
  •  Other
  •  I do not take any bone density medications
  •  Osteopenia
  •  Osteoporosis
  •  Cancer
  •  Other

The following questions refer to cancer history

  •  Yes
  •  No
  •  Yes
  •  No
  •  Surgery
  •  Chemo
  •  Radiation
  •  Homeopathic
  •  Other
MEDICAL HISTORY( * mandatory to fill )
  •  NONE
  •  HP Virus/oral sex
  •  Tobacco Use
  •  Heavy Drinking
  •  Family History
  •  NO
  •  Pre-diabetic
  •  Diet controlled
  •  Insulin-controlled
  •  Most Recent a1c

Misc

  •  Yes
  •  No
  •  Daily
  •  Weekly
  •  1-2 per month
  •  Rarely
  •  Never
  •  Yes
  •  No
  •  Cigarettes
  •  Cigars
  •  Chewing Tobacco
  •  E-cigarettes/vaping
  •  Yes
  •  No
  •  smoke/vape
  •  in food
  •  pills
  •  topical
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Phen-Fen
  •  Redux
  •  Other

Women Only

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

Allergies/Sensitivities

  •  I have no known allergies
  •  Amoxicillion or Penicillin
  •  Sulfa
  •  Z-Pak
  •  Cephalexin
  •  Cipro
  •  Other
  •  Aspirin
  •  Codeine
  •  Other
  •  Local anesthetic
  •  Epinephrine Sensitive
  •  Other
  •  Latex
  •  Metal or Nickel
  •  Acrylic
  •  Other
  •  I HAVE COMPLETED MY RESPONSES TO THE LIST OF CONDITIONS ON THE FOLLOWING PAGE

To the best of my knowledge, the questions on this form have been accurately and thoroughly answered. I understand that providing incorrect information can be dangerous to the patient's health. It is my responsibility to inform the dental office of any changes in medical status.

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MEDICAL ISSUES( * mandatory to fill )

Please review each of the following issues and check "NO" if you have no history of this issue. Please check "History" if it has occurred in the past with no ongoing concern. Please check "Current" if you currently have it or still have concerns from a previous event. Additional information may be requested for any of the issues that can affect your dental care. Please be thorough in your review of these issues.

Heart/Blood

  •  NO
  •  History
  •  Current
  •  Treating with meds
  •  Untreated
  •  NO
  •  History
  •  Current
  •  Treating with meds
  •  Untreated
  •  NO
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current

Breathing/Lung

  •  No
  •  History
  •  Current
  •  Yes
  •  No
  •  Could not tolerate
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
MEDICAL ISSUES( * mandatory to fill )

Liver/Kidney/Digestive

  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current

Illness or infection

  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current

Cognitive/Neurological/Hormonal

  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current

Skeletal/Skin

  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current

Misc

  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current
  •  No
  •  History
  •  Current

I have reviewed the above list of medical issues that can impact my dental care and have answered truthfully to the best of my knowledge.

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Hipaa information and consent 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 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 a 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 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 your 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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Patient Agreements and Authorizations( * mandatory to fill )

CONSENT FOR TREATMENT

I hereby consent to the treatment provided by Smile Pro Studio and its employees or designees. I authorize the dental care services deemed necessary or advisable by my care providers to address my needs.  I understand that all dental care involves some risks and no guarantees of the treatment outcome have been given.

AUTHORIZATION FOR RELEASE OF PERSONAL HEALTH INFORMATION.

I authorize use and disclosure of my personal health information for the purposes of diagnosing or providing treatment to me, obtaining payment for my care, or for the purpose of conducting the healthcare operations of the Practice. I authorize the Practice to release any information required in the process of applications for financial coverage for the services rendered. This authorization provides that the Practice may release objective clinical information related to my diagnoses and treatment, which may be requested by my insurance company or its designated agent.

ASSIGNMENT OF INSURANCE BENEFITS/ PAYMENT GUARANTEE/ COLLECTION FEE.

I authorize payment to be made directly to Smile Pro Studio for insurance benefits payable to me. I understand that I am financially responsible to the Practice for any covered or non-covered services, as defined by my insurer. I understand that if my account balance becomes overdue and the overdue account is referred to a collection agency, I will be responsible for the cost of collection including reasonable attorney’s fees.

PRIVACY POLICY.

I acknowledge I was offered the Practice’s, “Notice of Privacy Practices.” My rights, including the right to see and copy my record, to limit disclosure of my health information, and to request an amendment to my record, is explained in the Policy.  I understand that I may revoke in writing my consent for release of my health care information, except to the extent the Practice has already made disclosures with my prior consent.

PHOTOGRAPH RELEASE

I authorize the practice to take photographs and/or videos of my face, jaws and teeth, before, during and after treatment. I consent to allow the photographs to be used for the following: Dental Records and treatment planning;  Dental Research;   Dental Education including lectures, seminars, demonstrations, professional publications such as journals or books;   Marketing Material, including websites and printed materials;  Patient Education.   I further understand that if the photographs and/or videos are used, my name or other identifying information will be kept confidential.   I do not expect compensation, financial or otherwise, for the use of these photographs.

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  •  Authorized Person
  •  Patient
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