Online Patient Registration Form

CONTACT INFORMATION

Date

Title

Last Name

First Name

Address: Street

City/Town

Zip

Date of Birth

Home Phone

Cell Phone

Occupation

Place of Work

Work Phone

Spouse's Name

Spouse's Address

Spouse's Cell Number

Spouse's Employer

MEDICAL INFORMATION

Referring Dentist

Contact in Case of Emergency

Relationship

Phone

Reason for this Visit

Physician's Name

Phone

Are you now or have you been recently under the care of a physician?

Yes No

If yes, for what reason?

Check if you are taking any of the following medication:

Steroid

Synthroid

Coumadin

Plavix

Aspirin

NONE

List all medications you are currently taking, if any. If this is not applicable, please put NONE

Heart Attack: When?

Cancer: Type?

Major Operation: Type?

Prosthetic Joints: When?

Other

CHECK IF YOU HAVE HAD SENSITIVITY OR ALLERGIC RESPONSE TO ANY OF THE FOLLOWING:

Local Anesthetics

Epinephrine

Aspirin

Codeine

Latex

Iodine

Antibiotics

Others

NONE

If others, please specify.

Do you smoke tobacco?

Yes No

If yes, how much?

Women Only:

Are you pregnant?

Yes No

How many months?

Are you breastfeeding?

Yes No

Please indicate any special concerns related to your treatment such as dental anxiety.

BILLING AND DENTAL INSURANCE INFORMATION

UPLOAD DENTAL INSURANCE CARD

Card Front

Add file

Please upload a file

Card Back

Add file

Please upload a file

DENTAL INSURANCE COMPANY INFORMATION

*** If you do not have dental insurance to cover Endodontic treatment, please proceed to FINANCIAL AGREEMENT ***

Name of Dental Insurance

Dental Insurance Company Address for Claim Submission Including PO Box

PRIMARY INSURANCE SUBSCRIBER INFORMATION

Name

Address

DOB

Insurance ID# or SSN

Plan and/or Group#

Employer Name

UPLOAD SECONDARY INSURANCE CARD

Card Front

Add file

Please upload a file

Card Back

Add file

Please upload a file

SECONDARY INSURANCE COMPANY INFORMATION

*** If you do not have dental insurance to cover Endodontic treatment, please proceed to FINANCIAL AGREEMENT ***

Name of Dental Insurance

Dental Insurance Company Address for Claim Submission Including PO Box

SECONDARY INSURANCE SUBSCRIBER INFORMATION

Name

Address

DOB

Insurance ID#

Plan and/or Group#

Employer Name

AUTHORIZATIONS

I authorize insurance payments be made directly to the doctor for services rendered and understand that I am financially responsible for charges regardless of insurance coverage. To the extent permitted by law, I consent to the release of protected medical information to third parties as specified by HIPAA laws regarding Privacy Practices for the purpose of enabling the doctor to obtain payment for dental services rendered. I understand that if the third party is not a health care provider the released information may no longer be protected.

FINANCIAL AGREEMENT

I agree that I am financially responsible for all services rendered by the doctor regardless of insurance coverage. Estimated Copayment or if you do not have dental insurance then payment in full is due at the time dental services are rendered, unless other payment arrangements have been approved in writing in advance by our staff. I agree to pay reasonable attorney fees as limited by law and all costs of collection in case of default on payment of the account. I have certified that I have read and understand this form, and have received a copy of this document.

Please read and print the following for your records:
Notice of Privacy Practices
Risks of Treatment

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND RISKS OF TREATMENT

I have read and received a copy of this office’s Notice of Privacy Practices and Risks of Treatment provided above.

I have reviewed the information on this registration form and it is accurate to the best of my knowledge.

DISCLAIMER: By typing your name below, you are signing this ENTIRE registration form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this ENITRE registration form.

Patient or Guardian's Signature

Date

Financial Responsible Party’s Name (if different from above)

Date

Financial Responsible Party's Signature

Date

Your information will be encrypted.

Online Patient Registration Form

CONTACT INFORMATION

MEDICAL INFORMATION

BILLING AND DENTAL INSURANCE INFORMATION

UPLOAD DENTAL INSURANCE CARD

DENTAL INSURANCE COMPANY INFORMATION

UPLOAD SECONDARY INSURANCE CARD

SECONDARY INSURANCE COMPANY INFORMATION

AUTHORIZATIONS

FINANCIAL AGREEMENT

Please read and print the following for your records:Notice of Privacy PracticesRisks of Treatment

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND RISKS OF TREATMENT

Please read and print the following for your records:
Notice of Privacy Practices
Risks of Treatment