Patient Registration Form Fill Out Your Patient Registration Below "*" indicates required fields Step 1 of 5 20% Please take a moment to enter or update your information to help us ensure the quality of your care is excellent.Chart#: FOR OFFICE USE ONLY ↑First Name* MI Last Name* Preferred Name Title Mr/Ms/Mrs/etc.Gender* Male Female Family Status* Married Single Divorced Other Date of Birth* MM slash DD slash YYYY Prev. Visit* MM slash DD slash YYYY SS#* Email Address* Best time to call? Morning, Afternoon, etc.Home PhoneCell Phone*Work PhoneExt FaxAddress 1* Address 2 City* State*Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Code* Name of person, office, or other source referring you to our practice: Emergency ContactEmergency Contact Name* Emergency Contact Phone*Emergency Contact Email Responsible Party Information This only needs to be filled out if the responsible party is other than the patient, or you are the parent/guardian of the patient.Is the responsible party other than the patient, or are you the parent/guardian of the patient?* Yes No The following is for:* The patient's spouse The person responsible for payment The patient's parent/guardian First Name* MI Last Name* Preferred Name Title Mr/Ms/Mrs/etc.Gender* Male Female Family Status* Married Single Divorced Other Date of Birth* MM slash DD slash YYYY Email Address* Best time to call? Morning/Afternoon/etc.Home PhoneCell Phone*Work PhoneExt Address 1* Address 2 City* State*Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Code* Employment InformationEmployer Name PhoneAddress 1 Address 2 City StatePlease SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Code Insurance InformationDo you have dental insurance?* Yes No Primary Dental InsuranceName of InsuredFirst* MI Last* Insured's Birth Date* MM slash DD slash YYYY ID #:* Group #:* Insured's AddressAddress 1* Address 2 City* State*Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Code* Insured's Employer Name Employer Address 1 Employer Address 2 City StatePlease SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Code Patient's relationship to insured:* Self Spouse Child Other Insurance Plan Name* Insurance Company Phone #*Insurance AddressAddress 1 Address 2 City StatePlease SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Code Insurance Authorization* By checking this box,I authorize my insurance company to pay the dentist all insurance benefits rendered. I authorize the use of this electronic signature on all insurance submissions. I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.Do you have secondary dental insurance?* Yes No Secondary Dental InsuranceName of InsuredFirst* MI Last* Insured's Birth Date* MM slash DD slash YYYY ID #:* Group #:* Insured's AddressAddress 1* Address 2 City* State*Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Code* Insured's Employer Name Employer Address 1 Employer Address 2 City StatePlease SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Code Patient's relationship to insured:* Self Spouse Child Other Insurance Plan Name* Insurance Company Phone #*Insurance AddressAddress 1 Address 2 City StatePlease SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Code Insurance Authorization* By checking this box,I authorize my insurance company to pay the dentist all insurance benefits rendered. I authorize the use of this electronic signature on all insurance submissions. I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance. Dental HistoryWhat is your immediate concern?Is there anything about your smile that you would like to change?Previous Dentist Name* Previous Dentist Phone #*Date of most recent dental exam* MM slash DD slash YYYY Date of most recent x-rays* MM slash DD slash YYYY Past Dental Issues Please answer "Yes" to all that applyHad complications from past dental treatment?* Yes No Had trouble getting numb?* Yes No Had any reactions to local anesthetic?* Yes No Had/have braces or orthodontic treatment?* Yes No Do you experience dry mouth?* Yes No Any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth?* Yes No Does food get trapped between any teeth?* Yes No Have you ever whitened or bleached your teeth?* Yes No Have you experienced popping and/or clicking of your jaw joint?* Yes No Do you have difficulty chewing?* Yes No Do you clench or grind your teeth?* Yes No Do you wear or have you worn a bite appliance?* Yes No Do your gums bleed when brushing or flossing?* Yes No Treated for gum disease or were told that you have lost bone around your teeth?* Yes No Noticed an unpleasant taste or odor in your mouth?* Yes No Experienced gum recession?* Yes No Had any teeth become loose on their own (without injury)?* Yes No Experienced a burning sensation in your mouth?* Yes No Do you snore or wake up frequently during the night?* Yes No If any of the checked boxes need further explanation, please describe: Financial AgreementThis agreement is to inform you of your financial obligation to our practice. We are committed to providing you with the most comprehensive dental care using only the highest quality materials and technology available in the market today. We are also committed to providing you with upto-date information and educational tools so that you may fully participate in maintaining optimum oral health. This financial agreement is intended to facilitate our ability to provide excellent service to you while minimizing our administrative costs. We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your insurance company. Your insurance policy is an agreement between you, your employer, and the insurance company. Our practice is not a party to that agreement. If payment from your insurance company is not received within 60 days from date of service, you will be expected to pay the balance in full. All charges you incur are your responsibility regardless of your insurance coverage. We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly, for assistance in the management of your account. As a courtesy to you, we will help you process all your insurance claims. You may direct your insurance company to pay your benefits directly to our practice by signing the authorization on the Assignment of Benefits Agreement. In order for our practice to file your insurance claim, you must bring a completed dental insurance form or proof of insurance at each appointment. Your estimated copayment for treatment, which is the amount not covered by your insurance, is due at the time treatment is provided. Your estimated copayment may be adjusted after the time of treatment depending upon the final reconciliation of insurance payments. Please be aware that not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will never cover. Our practice accepts cash, personal checks, MasterCard, Visa, and Discover. Third-party, extended payment financing is available upon request and approval. Returned checks and balances older than 60 days will be subject to collection fees and finance charges at the rate of 1.5% per month (18% annually). Additionally, our practice does reserve the right to charge you for appointments that you cancel without a 48 hour notice or fail to show up to. Our team specifically reserves that time just for you and we appreciate your consideration. Please do not hesitate to ask if you have any questions regarding this financial agreement. We are committed to providing you with the ultimate experience in dental care.Consent* By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature for the Financial Agreement.HIPAA AcknowledgementI understand that I may inspect or copy the protected health information described by this authorization. I understand that at any time, this authorization may be revoked, when the office that receives this authorization receives a written revocation, although that revocation will not be effective as to the disclosure of records whose release I have previously authorized, or where other action has been taken in reliance on an authorization I have signed. I understand that my health care and the payment for my healthcare will not be affected if I refuse to sign this form. I understand that information used or disclosed, pursuant to this authorization, could be subject to re-disclosure by the recipient and, if so, may not be subject to federal or state law protecting its confidentiality.I allow this practice to disclose my Protective Health Information to the following individuals: (This information could include: Name, Diagnosis, Test Results, Images and Account Information.)NameRelationship to Patient Add RemoveConsent* By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature for the HIPAA Disclosure Form.Consent for Internet CommunicationsI grant my permission to the dental practice to upload and store confidential patient information (including account information, appointment information and clinical information) to the secured web site for the dental practice. I understand that, for security purposes, the site requires a user ID and password for access and use. I also understand the dental practice and I are responsible for maintaining the strict confidentiality of any ID and password assigned to me; and that the dental practice is not liable for any charges, damages, or losses that may be incurred or suffered as a result of my failure to maintain confidentiality. I understand the dental practice is not liable for any harm related to the theft of my ID and password, my disclosure of my ID and password, or my authorization to allow another person or entity to access and use the dental practice web site with my ID and password. I also agree to immediately notify the dental practice of any unauthorized use of my ID or of any other need to deactivate my ID due to security concerns. I also understand that State and Federal laws, as well as ethical and licensure requirements impose obligations with respect to patient confidentiality that limit the ability to make use of certain services or to transmit certain information to third parties. I understand the dental practice will represent and warrant that they will, at all times during the terms of this Agreement and thereafter, comply with all laws directly or indirectly applicable that may now or hereafter govern the gathering, use, transmission, processing, receipt, reporting, disclosure, maintenance, and storage of my information, and use their best efforts to cause all persons or entities under their direction or control to comply with such laws. I agree that the dental practice has the right to monitor, retrieve, store, upload and use my information in connection with the operation of such services, and is acting on my behalf in uploading my patient information. I understand the dental practice will use commercially reasonable efforts to maintain the confidentiality of all patient information that is uploaded to the web site on my behalf. I understand the dental practice CANNOT AND DOES NOT ASSUME ANY RESPONSIBILITY FOR MY USE OR MISUSE OF PATIENT INFORMATION OR OTHER INFORMATION TRANSMITTED, MONITORED, STORED, UPLOADED OR RECEIVED USING THE SITE OR THE SERVICES.Consent* I have read the information above regarding the secured uploading of patient information to the web site for the dental practice, and grant the dental practice permission to securely upload my patient information to the web site. This will serve as my electronic signature.CAPTCHANameThis field is for validation purposes and should be left unchanged.
