Patient Registration Form Patient Registration Form "*" indicates required fields First Name* Last Name* Birth Date* Social Security Number Gender* Male Female Address* Address * City * StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State * Zip * Home Phone*Cell Phone*Work PhoneEmail* Emergency Contact Name* Contacts Phone*Relationship to Patient* Preferred PharmacyPreferred Pharmacy* Cross Streets* How Did You Hear About Us?General Dentist* Referred By* How did you hear about us? Dentist Friend Internet Medical HistoryHigh Blood Pressure* Yes No Unknown Congenital Heart Defects* Yes No Unknown Diabetes* Yes No Unknown Cardiac Transplant* Yes No Unknown Angina Pectoris* Yes No Unknown Thyroid Condition* Yes No Unknown Heart Attack* Yes No Unknown Heart Surgery* Yes No Unknown Pain in Jaw Joints* Yes No Unknown Infective Endocarditis* Yes No Unknown Artificial Heart Valve* Yes No Unknown Bleeding Disorders* Yes No Unknown Stroke* Yes No Unknown Epilepsy* Yes No Unknown Seizures* Yes No Unknown Tuberculosis* Yes No Unknown HIV Positive* Yes No Unknown Drug Addiction* Yes No Unknown Hepatitis* Hep #A Hep #B Hep #C No Unknown Other Notable Condition: List Current Medications: Are you able to take ibuprofen?* Yes No Are you currently taking a blood thinner?* Yes No Have you ever had an unusual reaction to latex, anesthetics, or drugs such as penicillin, codeine, aspirin, or sulfa?* Yes No If yes, please explain: Are you required to take an antibiotic premedication 1 hour prior to dental appointments?* Yes No List reason and name of the antibiotic: Have you taken bisphosphonates?*(osteoporosis medication) Yes No Was it past or present? please explain: Please list medication: Women: Are you pregnant?* Yes No If yes, how far along: How are you feeling about your appointment? Confident Happy Curious Pained Anxious Frightened Yes. I have Dental Insurance Yes. I have Dental Insurance. Dental InsurancePolicy Holder Name* Relationship to Patient* Policy Holder Social Security* Policy Holder Birth Date* Insurance Company* Member ID Number* Group Number* Insurance Phone*Employer Name* Employer Address* Length of employment* Yes. I have Secondary Insurance Yes. I have Secondary Insurance. Secondary Dental InsurancePolicy Holder Name* First Relationship to Patient* Policy Holder Social Security* Policy Holder Birth Date* Insurance Company* Member ID Number* Group Number* Insurance Phone*Employer Name* Employer Address* Length of employment* Yes. This Patient is a Minor Yes. This Patient is a Minor. Responsible Party* Relationship to Patient* Policy Holder Birth Date* Same address and contact as minor Same address and contact as minor Address Address * City * StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State * Zip * Home PhoneCell PhoneWork PhoneEmail The purpose of Endodontic treatment (root canal therapy) is to save your tooth rather than remove it. Although this treatment has a high rate of success, it cannot be guaranteed. A tooth that has had root canal treatment may require re-treatment, surgery or eventual extraction. Before any treatment is started, the reason(s) will be explained as well as alternative modes of therapy. Occasionally, an antibiotic may be indicated. This will be discussed in advance. After treatment you must return to your general dentist to have your tooth restored with a permanent filling or crown. Fees incurred in another office are not included in our costs. I consent to necessary treatment and authorize the release of any information needed for continued care. I authorize the release of information to my insurance company & payment of benefits directly to provider. Any balance not paid by my insurance will be due within two weeks of the statement date. I am financially responsible for fees incurred at the time of service. In the event my account becomes delinquent, I understand a LATE FEE up to $10 and/or a SIMPLE INTEREST CHARGE will be added to the account. The INTEREST CHARGE will be at a periodic rate of 1.5% per month, which is an ANNUAL PERCENTAGE RATE of 18%, applied to the last month’s balance. Also, an additional 30% of the principal balance due will be added to help cover the cost of collection. I understand that I am responsible for attorney’s fees, interest, and court costs, should it become necessary that legal action be taken, and that a credit report will be obtained for the sole purpose of collecting a delinquent balance. Signature of Patient/Guardian of Minor* Today's Date
