New Patient Packet

Patient Registration Form

Name:

Date:

Address:

City:

State:

Zip:

Home Phone:

Cell Phone:

Types of Communication Acceptable for You:

Phone Text Email

Date of Birth:

Gender:

Male Female

Occupation:

Work Phone:

If Retired Please List Previous Occupation

Add another occupation

Place of Employment:

Marital Status:

Spouse’s name:

Emergency contact:

Phone #:

Dentist:

Phone #:

Physician:

Phone #:

Whom may we thank for referring you to our office?

Who is financially responsible for this bill?

How will the services be paid?

Cash

Check

Credit Card

Debit Card

*We are an Out-of-Network dental office. As a courtesy, we will be happy to e-file your claim and your insurance company will directly reimburse you. Please note that payment is due at time of service.

Do you have dental insurance?

Yes No

If yes please indicated name of employer providing the insurance:

Primary Dental Insurance:

Insurance Address:

Insured’s Name:

DOB of Subscriber:

Group/Policy #:

ID/SS #

I understand and agree that regardless of my insurance status, I am ultimately responsible for the balance of my account for any professional services rendered. I understand that all payment is due when services are rendered. I also agree that should my account be referred to a collection service and/or attorney for collection, I will be responsible for all reasonable collection service charges and/or court and other related expenses.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature:

Parent/legal guardian:

Date:

Medical History Form

Name:

Age:

Date:

Chief Complaint:

Put a (✓) check in the box if your answer is yes:

1. Are you in good health?

2. Has there been a change in your health in the past year?

3. Have you been hospitalized or had a serious illness in the last 3 years?

4. Are you being treated by a physician now?

5. Have you had problems with prior dental treatment?

6. Do you have fear or anxiety when going to the dentist?

7. Are you having pain now?

If you answer Yes on Question #3, Why?

If you answer Yes on Question #4,For what?

Date of last medical exam:

If you answer Yes on Question #5, Please Specify:

If you answer Yes on Question #6, Please choose:

Mild Moderate Severe

If you answer Yes on Question #7, If so, CHECK your pain level:

No Pain Slight Mild Moderate Severe Worst Pain

If you answer Yes on Question #51,Please specify

If you answer Yes on Question #55, Please specify:

If you answer Yes on Question #56, If so what antibiotic do you take?

Put a (✓) check in the box if you are taking any of the following:

66. Do you use recreational drugs?

67. Do you drink alcohol?

68. Bisphosphonates, now or in the past?

(medications like Fosamax, Zometa, and Boniva, used to treat osteoporosis and metastatic cancer)

69. Tobacco in any form?

70. Drugs, medications, over the counter (including aspirin), natural remedies?

71. Do you consume Grapefruit or Grapefruit products?

Women Only:

72. Is there any chance you may be pregnant

Yes No

73. Taking birth control pills?

Yes No

74. Are you nursing?

Yes No

All Patients:

Do you have or have you had any other diseases or medical problems NOT listed on this form?

Yes No

If so, please explain:

Please list ALL medications you are currently taking include OTC, Herbs, and Vitamins:

Add another medication

What specific OTC or Prescription medication are you taking for the dental condition you are here for today?

Please List All Allergies to Medications or Drugs:

Add another Allergy

To the best of my knowledge, I have answered every question completely and accurately, I will inform my dentist of any changes in my health and/or medications.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patients /Guardian Signature

Date:

HIPAA Consent (For Use or Disclosure of Health Information)

This form must be completed by the individual whose protected health information is to be disclosed or by a parent or guardian if the person is a minor under state law.

Name

I hereby authorize Dr. Michael Sardzinski to release the following personal health information for: (check all that apply)

Insurance claims information

Referring Dentist and/or General Dentist

Prescription, diagnostic, treatment, and/or management services

Other

If Other, please specify:

The above information may be released by:

Phone or Fax

Mail or E-mail

Friend or Relative

My Consent

Effective: Today’s Date

I want this consent to:

Continue Indefinitely

Effective Only Until:

I understand that consent may be revoked by me at any time. I understand why I have been asked to disclose this information and am aware that my patient rights are identified in the practice’s Notice of Privacy Practices.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient:

Date:

Or, Personal Representative:

Date:

Your information will be encrypted.