Patient Registration

Today's Date

Patient's Name (Mr./Mrs.)

SS#

Date of Birth

Sex

Residence Address

Email address

City

State

Zip

Home Phone

Occupation

Employer

Cell Phone

Name of Spouse

SS#

Date of Birth

Occupation

Employer

Business Phone

Responsible Party if Patient is a Minor

Relationship to Minor

Name, Address, and Phone of Relative NOT Living with you

Party Responsible for Payment of Account

INSURANCE 1st COVERAGE

INSURANCE 2nd COVERAGE

Employee Name

Employer

Name of Ins. Co.

Address

Group #

Member ID or SS #

Birthdate

ASSIGNMENT, RELEASE, AND ACKNOWLEDGEMENT: I hereby authorize my insurance benefits to be paid directly to the dentist. I am financially responsible for any balance due. I also authorize to release any information required for this claim. In addition, in consideration of the service rendered to me by this dental office, I am obligated to pay said office in accordance with its credit terms and policy.

Additionally, my signature confirms that I have been informed of my rights to privacy regarding my protected health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that this information can and will be used to: 1) Provide and coordinate my treatment among number of health care providers who may be involved in that treatment directly and indirectly. 2) Obtain payment from third-party payers for my health care services. 3) Conduct normal health care operations such as quality assessment and improvement activities.

I have been informed of my dental provider's Notice of Privacy Practices containing a more complete description of the uses and disclosures of my protected health information. I have been given the right to review and receive a copy of such Notice of Privacy Practices. I understand that my dental provider has the right to change the Notice of Privacy Practices and that I may contact this office at the address above to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations and I understand that you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

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.

Patient's (or Authorized Representative) Signature

Today's Date

Dental History

How did you hear about our office?

Your Previous Dentist

City/State

How long?

When was you last Dental Cleaning?

Cleanings per year?

How often do you brush?

Floss?

See your dentist?

DO YOU HAVE OR HAVE YOU EVER HAD

1.) Head or neck injuries

Yes No

2.) Sore or sensitive teeth

Yes No

3.) Bleeding gums

Yes No

4.) Grind or clench teeth

Yes No

5.) Difficulty chewing

Yes No

6.) Anxiety of dental treatment

Yes No

7.) Sores on lips/mouth that are slow to heal

Yes No

8.) Dissatisfaction with appearance of your teeth

Yes No

9.) Periodontal Disease (Pyorrhea)

Yes No

10.) Trouble opening/closing your jaw

Yes No

11.) Reactions to anesthetic ("Novocaine")

Yes No

12.) Bleeding or slow healing after extraction

Yes No

13.) Do you have any interest in cosmetic dentistry?

Yes No

Your information will be encrypted.