Patient Registration Form

Patient Registration

Name

Sex

Male Female

Martial Status

Date of Birth

SSN

Email address

Address

City

State

Zip

Cell Phone

Home Phone

Work Phone

If Patient is under 18 years old:

Name of Parents or Legal Guardian

Address if Different than Patient:

Home Phone

Work Phone

Person Responsible for Payment

Address

City

State

Zip

Date of Birth

SSN

DL#

Employer

City

State

Zip

Dental Insurance Coverage

Patient Relationship to the insured

Self Spouse Child Other

Insured's Name

SSN

Date of Birth

Insured ID#

Employer Name

Group #

Employer Address

Employer Phone #

Insurance Co. Name

Insurance Co. Phone #

Address

City

State

Zip

How were you referred to our practice?

I understand the treatment I have received and if applicable the following treatment plan. I authorize release of any information relating to this dental claim. I understand that I am responsible for all costs of dental treatment.

Signature

Date

I hereby authorize payment of the dental benefits be sent directly to Dr. Thomas E. Long.

Signature

Date

Patient Medical History

Name of Physician

Phone #

1. Are you in good health?

Yes No

2. Has there been any change in your general health in the last year?

Yes No

If yes, please explain:

3. Have you ever been hospitalized, had a major operation or serious illness?

Yes No

If yes, please explain:

4. Have you ever had surgery?

Yes No

If yes, when and what for:

5. Date of your last visit to your doctor?

Reason for last visit

6. Are you now under a doctor’s care for a particular problem at this time?

Yes No

If yes, for what condition(s)?

Other Medications if applicable:

8. Are you allergic to or have you had any reactions to the following?

Penicillin

Aspirin

Codeine

Sulfonamides

Barbiturates

Iodine

Latex

Other (Please List):

Other Allergies if applicable:

Have you ever had or been treated by a doctor for:

9. Damaged heart valves or artificial heart valves, including heart murmur, pacemaker, rheumatic fever, rheumatic heart disease?

Yes No

10. Congenital heart problems?

Yes No

11. Heart trouble, heart attack, high blood pressure, stroke?

Yes No

11a. Do you have pain in your chest upon exertion?

Yes No

11b. Are you ever short of breath after mild exercise?

Yes No

11c. Do your ankles swell?

Yes No

12. Prosthetics/Knee replacement or Organ transplant?

Yes No

13. Severe or frequent headaches or sinus problems?

Yes No

14. Blood disorders such as anemia or hemophilia?

Yes No

15. Blood transfusion?

Yes No

16. Breathing problems, emphysema, tuberculosis, or other lung problems?

Yes No

17. Asthma, hay fever, or hives?

Yes No

18. Stomach or intestinal disease, or ulcers?

Yes No

19. Cancer, x-ray treatments, or chemotherapy?

Yes No

20. Diabetes or blood sugar problems?

Yes No

21. Hepatitis, jaundice, or liver disease?

Yes No

22. Kidney infections, frequent urination, or renal (kidney) dialysis?

Yes No

23. Stroke, seizures, fainting spells, numbness or other neurological problems?

Yes No

24. Syphilis, gonorrhea, or genital herpes?

Yes No

25. AIDS, AIDS related condition, or HIV positive?

Yes No

26. Tumors or growths?

Yes No

27.Arthritis or rheumatism?

Yes No

28. Phobias, severe anxieties, depression, psychoses, unusual fears or other mental problems?

Yes No

29. Psoriasis, seborrhea, or other skin diseases?

Yes No

30. Have you lost weight without dieting or gained weight in recent months?

Yes No

31. Do you smoke cigars/cigarettes?

Yes No

32. Do you drink alcoholic beverages?

Yes No

33. For women, are you pregnant or do you think you may be pregnant?

Yes No

34. Please describe any other problems about your health that you know of:

35. What is your major dental concern?

36. Date of your last visit to a dentist

37. Date you last had dental x-rays taken?

38. Reason for your last visit?

39. Are you required, by your physician, to premedicate prior to dental procedures?

Yes No

40. Have you ever experienced an unusual reaction to dental medication or anesthetic?

Yes No

41. Are you happy with the appearance of your teeth?

Yes No

42. Do your gums bleed when you brush your teeth or when you eat?

Yes No

SIGNATURE OF PATIENT: I understand the need for these questions to be answered truthfully. To the best of my knowledge, the answers I have given are accurate. I also understand it is very important to report any changes in my medical or dental status to the dentist at the earliest possible time, and I agree to do so. I give permission to the dentist to obtain from my physician any additional information regarding my medical history needed to provide me with the best dental treatment possible.

Signature

Date

Emergency Contact Person

Phone #

Consent for Treatment

1. I hereby authorize Dr. Thomas E. Long or designated staff to take x-rays, study models, photographs, and any other diagnostic aids deemed appropriate to make thorough diagnosis for patient's dental needs (Provide patient's name below).

Name of Patient

2. Upon such diagnosis, I authorize Dr. Thomas E. Long or designated staff to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.

3. I understand that this office files my insurance claims as a courtesy. Any claim not paid within 45 days of treatment is my responsibility.

4. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that payment is due at the time of service unless other arrangements have been made.

5. Lastly, I have received a copy, reviewed, and hereby agree to all office policies.

Person completing this form:

Signature

Date

Relationship to Patient

I allow the office of Dr. Tom Long to confirm my appointments by email and/or text message.

ACKNOWLEDGEMENT OF RECIEPT OF HIPPA PRIVACY PRACTICES

NOTE: You may refuse to sign this acknowledgement.

I have reviewed a copy of this office’s HIPPA Notice of Privacy Practices.

Please list anyone you wish to share information with.

Signature

Date

Your information will be encrypted.