New Patient form

PATIENT INFORMATION AND HISTORY

Last name:

First Name:

Middle Initial:

Age:

Birthdate:

Sex:

Male Female

Address Number:

Street:

City:

State:

Zip Code:

Social Security:

Email:

Tel #:

Occupation:

Employer:

Bus. Tel #:

Referred By:

Dentist:

Physician:

SPOUSE, PARENT, OR OTHER GUARANTOR INFORMATION IF DIFFERENT THAN ABOVE

Who will be responsible for your account?

Spouse

Mother

Father

Other

Name

Birth Date

SS#

Address

Tel #

Employer:

SS#

Bus Tel #

PRIMARY DENTAL INSURANCE

Policy Holder

SS#

Birth Date

Dental Company

Group #

Member ID#

SECONDARY DENTAL INSURANCE

Policy Holder

SS#

Birth Date

Dental Company

Group #

Member ID#

Height:

Weight:

1. Are you under any medical treatment now?

Yes No

2. Are you taking any drugs or any medication now?

Yes No

If Yes, Please list medications (including over the counter weight reduction medications)

Add new row

3. Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?

Yes No

If yes, please specify.

4. Have you had any major operations recently?

Yes No

If yes, please specify.

5. Have you ever had any joint or valve replacements in the past 2 years?

Yes No

6. Have you or your relatives had a bad reaction to anesthesia?

Yes No

If other, please specify.

8. Have you ever had a serious accident involving head or neck injuries?

Yes No

If yes, please specify.

10. Do you/did you abuse alcohol or drugs?

Yes No

11. Do you have a severe gag reflex?

Yes No

12. Have you had any abnormal oral bleeding?

Yes No

13. Do you smoke or use tobacco?

Yes No

Quit

14. (Female) Are you or could you be pregnant?

Yes No

Nursing?

Yes No

Oral Contraceptive?

Yes No

15. Have you ever had any serious illness not listed?

Yes No

If yes, please specify.

Authorize Privacy Practice Notice

I hereby acknowledge that a copy of Green Bay Endodontics's Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask questions I may have regarding this Notice.

Patient/Parent (Guardian) Initials:

Authorization to Release All information to:

Relationship:

I understand that by initialing below I am confirming the use and disclosure of my protected health information to the authorized person(s) listed above. Authorization is good until I choose to revoke it

Patient/Parent (Guardian) Initials:

DECLINE RELEASE OF MY INFORMATION

I hereby confirm that the above facts are true to the best of my knowledge. I will not hold my doctor or any other member of his/her staff responsible for any errors or omissions that I have made in the completion of this form.

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

Signature

Date

RESPONSIBILITY FOR PAYMENT

PATIENT NAME:

I agree to be and am fully responsible for total payment of services performed including any amounts not covered by any dental insurance, I may have.

I understand that the parent who requests treatment and/or presents a minor child for treatment is responsible for all fees for services rendered. In case of divorce, any arrangements made through a divorce agreement are strictly between the parents and do not involve the clinic.

I understand that clinic bills are due at the time of service regardless of any insurance coverage. Insurance is designed to reimburse the policyholder and is a contract between the policy holder and the insurance company. The clinic has an insurance department and will do all it can to help collect legitimate claims. In the event the insurance company is slow to pay; reduces payment because in their estimation the charges are over usual and customary; or for some reason disallows the claim, I understand payment of the account is my responsibility.

(IF INSURED) I authorize the release of information including records and x-rays requested by my insurance company for the purpose of determining pretreatment estimates, precertification or payment of insurance benefits. A copy of this authorization shall be as valid as the original.

Signature of Patient or Parent/Guardian Requesting Care:

Date:

If guardian responsible for payment is other than parent:

Name:

Relationship:

Address:

Phone:

Your information will be encrypted.