Patient Registration

1New Patient Registration Form

2Do You Have Insurance Insurance Coverage?

3Assignment of Benefits and Payment Policy

4Medical History

5Dental History

6Personal Information Consent Form

Name*
First Last
Date of Birth*
DD slash MM slash YYYY
Sex*
- Male
- Female
Home Phone*
Work Phone
Cell Phone
Prefered Contact*
HOME / WORK / CELL
PATIENT’S MAILING ADDRESS*
Street Address City State / Province / Region ZIP / Postal Code Country
E-MAIL ADDRESS*
PATIENT’S GUARDIAN (IF UNDER 18)
Name
Home Phone
Work Phone
PERSON WE CAN CONTACT IN CASE OF AN EMERGENCY
(OTHER THAN YOUR FAMILY HOME)
Name*
Home Phone / Cell Phone*
Work Phone
IF THIS IS YOUR FIRST VISIT, HOW DID YOU HEAR ABOUT OUR OFFICE?
Referred by another person
Other

Primary Coverage Insurance
Primary Coverage Insurance Co. Name
Subscriber Name
Date of Birth
DD slash MM slash YYYY
Certificate/Policy #
Subscriber ID
Secondary Coverage Insurance
Secondary Coverage Insurance Co. Name
Subscriber Name
Date of Birth
DD slash MM slash YYYY
Certificate/Policy #
Subscriber ID

This office is willing to accept direct payment from your dental plan only If your plan allows for assignment of benefits, for the cost of those dental services which we may provide.

Dental plans in the marketplace today are too numerous and varied to allow us to know the details of all of them. Your particular dental plan may or may not cover the full extent of the costs you incur for your dental treatment. This can occur because the fees in our office are based on factors which may not have been considered by your insurance carrier. Furthermore, there may be certain procedures performed which are not covered through your dental plan. These factors are beyond our control.

PLEASE REVIEW YOUR DENTAL PLAN VERY CAREFULLY TO ENSURE YOU UNDERSTAND THE EXCLUSIONS AND LIMITATIONS OF YOUR PLAN. IF YOUR DENTAL PLAN DOES NOT COVER THE FULL COST OF TREATMENT, YOU WILL BE RESPONSIBLE FOR ANY DIFFERENCE BETWEEN THE AMOUNT PAID BY YOUR PLAN AND THE AMOUNT CHARGED FOR YOUR TREATMENT.

Payment for dental services is expected when treatment is rendered. You will be informed of your payment or co-pay responsibility at the time treatment is completed so that you may make payment at that visit. A 2% service charge will be applied to all account balances outstanding for more than 30 days.

I hereby authorize my insurance benefits to be paid directly to the dentists. I am financially responsible for any balances due and authorize the dentists to release any information for any claim. I authorize that the doctor can use my records if he/she so determines.

I certify that I have read or had read to me the contents of this form, filled in completely and accurately to the best of my knowledge and do realize the risks and limitations involved.
Patient/Guardian Signature*
Date*
DD slash MM slash YYYY

Physician*
(Medical Doctor) / and their specialty
Most recent physical examination*
Purpose*
What is your estimate of your general health?*
- Excellent
- Good
- Fair
- Poor
Specify illness/injury that required hospitalization
All Allergies – Specify
Describe any current medical treatment, impending surgery, other treatment that may possibly affect your dental treatment. (i.e. Botox, Collagen Injections)
Current Medications
Include supplements, vitamins and recreational; all may affect your dental treatment.
Drug Purpose
Check Medical Conditions that Apply
- Heart Attack
- Endocarditis
- Heart Valve Replacement
- Cardiac
- Stent
- Pacemaker
- Angina
- COPD/Lung Disease
- Asthma
- Bronchitis/Pneumonia
- Emphysema
- Sleep Apnea
- Sinusitis/Sinus Obstruction
- Tuberculosis
- Rheumatic/Scarlet Fever
- Measles
- Chicken pox
- Kidney Disease
- Liver Disease
- Jaundice
- Thyroid
- Hormone Deficiency
- Anemia/Blood disorder
- Bleeding Disorder INR>3.5
- Diabetes HbA1c
- High Cholesterol
- High/Low Blood Pressure
- Fainting
- Stroke
- Tumor
- Radiation Therapy
- Chemotherapy
- Immunosuppressive Therapy
- Stomach/duodenal Ulcer
- Hernia
- Acid Reflux
- Celiac’s/digestive disorders
- Arthritis
- Rheumatoid Arthritis
- Osteoporosis/Osteopenia
- Lupus
- HIV/AIDS
- Head/Neck Injuries
- Migraines
- Epilepsy
- Down Syndrome
- Autism
- ADD/ADHD
- Anxiety
- Depression
- Fibromyalgia
- Psychiatric Disorders
- Neurological Disorders
- Glaucoma
- Others not listed
Are You ?
Presently being treated for any other illness?*
- Yes
- No
Aware of a change in your health in the last 24 Hour?*
(i.e. fever, chells, new cough, diarrhea)
- Yes
- No
Often exhausted or fatigued?*
- Yes
- No
Experiencing frequent headaches?*
- Yes
- No
A smoker or previous smoker, vaper, or use smokeless tobacco?*
- Yes
- No
FEMALE – Pregnant ?
- Yes
- No
Pregnancy Due Date:
DD slash MM slash YYYY
MALE – Prostrate disorders ?
- Yes
- No

We are committed to protecting the privacy of our patients’ personal information and to utilizing all personal information in a responsible and professional manner. This document summarizes some of the personal information that we collect, use and disclose. In addition to the circumstances described in this form, we also collect, use and disclose personal information when permitted or required by law.

We collect information from our patients such as names, home addresses, home and/or work telephone numbers, and email addresses (collectively referred to as “Contact Information”).

Contact information is collected and used for the following purposes:
- To open and update patient files
- To invoice patients and/or legal guardians or persons financially responsible for patient accounts, for dental services, to process credit card payments, or to collect unpaid accounts.
  To process claims for payment or reimbursement from third-party benefit providers, insurance companies and government agencies.
- To send reminders to patients concerning the need for further dental examination or treatment.
- To send patients informational material about our dental practice.
Contact Information is disclosed to third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patient’s behalf.

Financial information may be collected in order to make arrangements for the payment of dental services from whoever has been written as financially responsible for the account.

We collect information from our patients about their health history, their family health history, physical condition, and dental treatments (collectively referred to as “Medical Information”). Patients’ Medical Information is collected and used for the purpose of diagnosing dental conditions and providing dental treatment.

Patient’s Medical Information that is disclosed:
- To other dentists, dental specialists, health care providers and physicians, where further information and/or discussion is required or a where a patient has been referred to or from for treatment.
- Seeking and/or providing information to the following: Laboratories, Radiology Centres, Hospitals, etc.
- To include the following when necessary, such as: videos, pictures, slides, etc., for educational purposes.
If we are ever considering selling all or part of our dental practice, qualified potential purchasers may be granted access as part of the due diligence process, to patient information in order to verify information important to the potential sale. If this occurs, we will take steps to ensure the prospective purchaser safeguards all personal information.

Dentists are regulated by the Royal College of Dental Surgeons of Ontario, which may inspect our records and interview our staff as part of its regulatory activities in the public interests.

I consent to the collection, use and disclosure of my personal information as set out above.
Patient/Guardian Signature*
Date*
DD slash MM slash YYYY

Patient Registration

PATIENT’S GUARDIAN (IF UNDER 18)

PERSON WE CAN CONTACT IN CASE OF AN EMERGENCY

IF THIS IS YOUR FIRST VISIT, HOW DID YOU HEAR ABOUT OUR OFFICE?

Primary Coverage Insurance

Secondary Coverage Insurance

Are You ?

WHAT IS YOUR IMMEDIATE CONCERN?

GUM AND BONE

TOOTH STRUCTURE

BITE AND JAW JOINT

SMILE CHARACTERISTICS

Drug	Purpose