Patient Registration Forms

We are looking forward to your upcoming appointment time reserved in our office for a new patient evaluation. Drs. Morris and Morris are dedicated to providing you with the best dental care for your needs.

Please take a few minutes to fill out this very important patient registration. The health history is extremely important so we will know if there are any risks or allergies that may affect your oral health.

As a courtesy to our patients, we will gladly file any insurance benefits. Please be prepared to pay your co-payment, or total balance in full if you do not have insurance benefits. Unfortunately, we cannot accept Medicaid. PATIENTS COVERED BY DELTA DENTAL MAY BE REQUIRED TO PAY IN FULL AT THE TIME OF SERVICE. We will file the insurance claim for you and Delta Dental Will reimburse you.

We have reserved this appointment time, especially for you. If you cancel your appointment with less than 48 hours' notice, there will be a $25 fee. Our doctor's time is valuable and a broken appointment is a loss to you and to other patients who could use this appointment time.

Drs. Morris and Morris both have allergies and are asthmatic. Please respect their health and do not wear any perfumes or colognes to your appointment. We apologize for any inconvenience this may render.

Thank you for taking the time to read this and for completing this patient registration. We look forward to having you in our practice.

Drs. Morris and Morris and Staff

Patient Full Name

Nickname

Address

City

State

Zip

Social Security No.

Date of Birth

Parent/Guardian's name if patient is a minor

Primary Phone No.

Can we text you?

Yes

Email address

Can we email you?

Yes

Dental Insurance Carrier?

Employer's Name & Address

City

State

Zip

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In case of an emergency, whom should we contact?

Name

Relationship

Phone No.

Whom may we thank for referring you to our office?

Who will pay your bill?

Office Payment And Broken Appointment Policy

PLEASE NOTE: WE ARE NOT CONTRACTED WITH ANY INSURANCE CARRIERS!

We are considered out of network providers.

Patient's with dental insurance: We will be happy to file your insurance for you, but you must furnish us with the correct insurance information, and a copy of your insurance identification card. We will ESTIMATE your percentage of services based on your policy and you are expected to pay your portion when the services are rendered. This can range from a few dollars to 100% of the procedure. Remember that most insurance policies have a yearly deductible which must be met. You are responsible for any amount that your insurance does not pay. Our contract is with you, not your insurance carrier.

Patient's who fail to pay their bill (in a timely manner): Your account will be charged at a rate of 1.5% MPR (18% APR) and /or a $2.00 billing charge for any balance 30 days or more overdue. We also utilize a collection agency which adds the agency's charges to the account balance. This charge is 25% of the account balance.

Broken appointments are scheduled appointments that are cancelled without a minimum of 48 hours notice prior to the appointment time. Patient's who fail to show up or call will be charged a broken appointment fee.

I have read and understood the information presented to me.

Initials

DENTAL HISTORY

1. Reason for visit

2. When was your last dental visit?

3. How often do you brush your teeth?

If you could change the appearance of your teeth what would you change?

MEDICAL HISTORY

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry that you will be receiving. Thank you for answering the following questions.

Physician's Name, Phone Number, & Address

Date of your last physical exam

Have there been any changes in your general health within the past year?

Have you ever been hospitalized for any surgical operation or serious illness? If yes, Please explain

Are you taking any medicine(s) including non-prescription medicine? If yes, what medicine(s) are you taking?

Have you had a recent weight loss? If yes, Please explain

Do you smoke?

Yes

Do you vape or use smokeless tobacco?

Yes

Do you use alcohol? If so no. of drinks per week?

History of substance abuse?

WOMEN ONLY

Are you allergic to or have you had reactions to:

Local anesthetics like Novocaine?

Penicillin

Other Antibiotics?

Barbiturates, sedatives or sleeping pills?

Aspirin?

Iodine?

Metals or any dental materials?

Food

Other

If food, or other, Please specify

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I, the undersigned, have filled out the patient information online, read the above information, and I agree to it. I certify that I am the patient, or duly authorized general agent of the patient, authorized to furnish the information requested.

Signature

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