Template - Forms - Patient Registration & History



Patient InformationDate: FORMTEXT ????? FORMCHECKBOX New Patient FORMCHECKBOX UpdatePatient: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????LastFirstMI FORMCHECKBOX Male FORMCHECKBOX Female FORMCHECKBOX Child* FORMCHECKBOX Student** FORMCHECKBOX Single FORMCHECKBOX Married FORMCHECKBOX Divorced FORMCHECKBOX Widowed*If Child, provide parent/guardian name(s) below:**If Student, please complete: FORMCHECKBOX Full-time FORMCHECKBOX Part-Time FORMTEXT ????? FORMTEXT ?????Parent/Guardian Name(s)School/LocationPatient Date of Birth: FORMTEXT ?????Patient SSN: FORMTEXT ?????Address: FORMTEXT ?????Please indicate preferred contact method.Address Line 1 FORMTEXT ?????Home: FORMTEXT ???? FORMCHECKBOX Address Line 2Cell: FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Work: FORMTEXT ????? FORMCHECKBOX CitySTZIP CodeE-Mail: FORMTEXT ?????Referral? FORMCHECKBOX Yes FORMCHECKBOX NoReferred by: FORMTEXT ?????emergency InformationIn case of emergency, please provide information for the nearest relative or designated contact person not at the patient’s address: FORMTEXT ????? FORMTEXT ?????Tel #: FORMTEXT ?????NameRelationshipemployment InformationEmployer: FORMTEXT ?????Occupation: FORMTEXT ?????Address: FORMTEXT ?????Address Line 1Work: FORMTEXT ?????Direct: FORMTEXT ?????Address Line 2Other: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????CitySTZIP Code FORMTEXT ?????E-Mail: FORMTEXT ?????insurance InformationSubscriber: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????LastFirstMISubscriber Date of Birth: FORMTEXT ?????Subscriber SSN: FORMTEXT ?????Subscriber Employer: FORMTEXT ?????Patient Relationship to Subscriber: FORMCHECKBOX Self FORMCHECKBOX Spouse FORMCHECKBOX Child FORMCHECKBOX Other FORMTEXT ?????Primary Insurance Carrier : FORMTEXT ????? Plan name:Group/Policy No.: FORMTEXT ?????ID No.: FORMTEXT ?????Address: FORMTEXT ?????Tel: FORMTEXT ????? FORMTEXT ?????Toll-free: FORMTEXT ?????CityStateZip CodeFax: FORMTEXT ?????Patient Relationship to Subscriber: FORMCHECKBOX Self FORMCHECKBOX Spouse FORMCHECKBOX Child FORMCHECKBOX Other FORMTEXT ?????Secondary Insurance Carrier: FORMTEXT ?????Group/Policy No.: FORMTEXT ?????ID No.: FORMTEXT ?????Address: FORMTEXT ?????Tel: FORMTEXT ????? FORMTEXT ?????Toll-free: FORMTEXT ?????CityStateZip CodeFax: FORMTEXT ?????Patient Relationship to Subscriber: FORMCHECKBOX Self FORMCHECKBOX Spouse FORMCHECKBOX Child FORMCHECKBOX Other FORMTEXT ?????Former Dentist InformationDentist:Telephone: FORMTEXT ?????Address: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????CitySTZIP CodeReason for changing: FORMTEXT ?????dental historyOral Health: FORMCHECKBOX Excellent FORMCHECKBOX Good FORMCHECKBOX Fair FORMCHECKBOX PoorDate of Last Dental Visit: FORMTEXT ?????Treatment Type: FORMTEXT ????? FORMCHECKBOX Y FORMCHECKBOX NBurning sensation on the tongue FORMCHECKBOX Y FORMCHECKBOX NMouth pain, brushing FORMCHECKBOX Y FORMCHECKBOX NChew on one side of the mouth FORMCHECKBOX Y FORMCHECKBOX NOrthodontic treatment FORMCHECKBOX Y FORMCHECKBOX NCigarette, pipe or cigar smoking FORMCHECKBOX Y FORMCHECKBOX NPain around the ear FORMCHECKBOX Y FORMCHECKBOX NClicking or popping jaw FORMCHECKBOX Y FORMCHECKBOX NPeriodontal treatment FORMCHECKBOX Y FORMCHECKBOX NDry Mouth FORMCHECKBOX Y FORMCHECKBOX NSensitivity to cold FORMCHECKBOX Y FORMCHECKBOX NFingernail biting FORMCHECKBOX Y FORMCHECKBOX NSensitivity to Heat FORMCHECKBOX Y FORMCHECKBOX NFood collection between teeth FORMCHECKBOX Y FORMCHECKBOX NSensitivity to sweets FORMCHECKBOX Y FORMCHECKBOX NForeign objects FORMCHECKBOX Y FORMCHECKBOX NSensitivity when biting FORMCHECKBOX Y FORMCHECKBOX NGrinding teeth FORMCHECKBOX Y FORMCHECKBOX NSores or growths in your mouth FORMCHECKBOX Y FORMCHECKBOX NGums swollen or tenderHow often do you floss? FORMCHECKBOX Y FORMCHECKBOX NJaw pain or tiredness FORMCHECKBOX Y FORMCHECKBOX NLip or cheek bitingHow often do you brush? FORMCHECKBOX Y FORMCHECKBOX NLoose teeth or broken fillings FORMCHECKBOX Y FORMCHECKBOX NMouth BreathingChild/Minor Patients: Please answer the following questions: FORMCHECKBOX Y FORMCHECKBOX NAny mouth habits? (thumb sucking, nail biting, mouth breathing, nursing/bottle habits, pacifier, etc.) FORMTEXT ????? FORMCHECKBOX Y FORMCHECKBOX NAny unusual speech habits? If yes, explain: FORMTEXT ????? FORMCHECKBOX Y FORMCHECKBOX NAny lost teeth? If yes, list: FORMTEXT ????? FORMCHECKBOX Y FORMCHECKBOX NDoes the patient receive assistance with brushing and flossing? If yes, how often? FORMTEXT ?????primary physician InformationPharmacy InformationPhysician: FORMTEXT ?????Pharmacy Name: FORMTEXT ?????Telephone: FORMTEXT ?????Telephone:Medical HistoryGeneral Health: FORMCHECKBOX Excellent FORMCHECKBOX Good FORMCHECKBOX Fair FORMCHECKBOX Poor FORMCHECKBOX Y FORMCHECKBOX NUnder a physician’s care now? FORMCHECKBOX Y FORMCHECKBOX NAny hospitalization in the past 5 years? Describe: FORMCHECKBOX Y FORMCHECKBOX NAny serious illnesses/surgeries?Describe: FORMCHECKBOX Y FORMCHECKBOX NUse tobacco in any form? If Yes, Type: FORMCHECKBOX Y FORMCHECKBOX NIs pre-medication required before dental visits due to heart condition or artificial joint? FORMCHECKBOX Y FORMCHECKBOX NTaking any prescription or daily OTC medications/drugs? If yes, list details in the Medication Section.Female Patients: FORMCHECKBOX Y FORMCHECKBOX N Currently nursing? FORMCHECKBOX Y FORMCHECKBOX N Currently pregnant?Due Date: FORMTEXT ?????All Patients: Do you have, or have you ever had any of the following? (Check all that apply): FORMCHECKBOX None FORMCHECKBOX Acid Reflux FORMCHECKBOX Cortisone Medicine FORMCHECKBOX Osteoporosis FORMCHECKBOX ADHD FORMCHECKBOX Cough, persistent or Bloody FORMCHECKBOX Pacemaker FORMCHECKBOX AIDS/HIV FORMCHECKBOX Depression FORMCHECKBOX Pain in Jaw joints FORMCHECKBOX Alzheimer’s FORMCHECKBOX Diabetes FORMCHECKBOX Psychiatric Treatment FORMCHECKBOX Anaphylaxis FORMCHECKBOX Dizziness/Fainting FORMCHECKBOX Radiation FORMCHECKBOX Angina FORMCHECKBOX Emphysema FORMCHECKBOX Renal Dialysis FORMCHECKBOX Anemia FORMCHECKBOX Epilepsy/seizures FORMCHECKBOX Respiratory Disease FORMCHECKBOX Anorexia FORMCHECKBOX Frequent Ear Infections FORMCHECKBOX Rheumatic Fever FORMCHECKBOX Anxiety FORMCHECKBOX Frequent Headaches FORMCHECKBOX Seasonal Allergies FORMCHECKBOX Artificial Heart Valve FORMCHECKBOX Glaucoma FORMCHECKBOX Shingles FORMCHECKBOX Arthritis FORMCHECKBOX Hearing problems FORMCHECKBOX Sinus Problems FORMCHECKBOX Asthma FORMCHECKBOX Heart Attack FORMCHECKBOX Stroke FORMCHECKBOX Autism/Asperger’s FORMCHECKBOX Heart Disease FORMCHECKBOX Swollen Feet or Ankles FORMCHECKBOX Bleeding Disorder FORMCHECKBOX Heart murmur FORMCHECKBOX Swollen Neck Glands FORMCHECKBOX Breathing Problems FORMCHECKBOX Hepatitis FORMCHECKBOX Thyroid Condition FORMCHECKBOX Bulimia FORMCHECKBOX herpes FORMCHECKBOX Tonsillitis FORMCHECKBOX Cancer FORMCHECKBOX High/Low Blood Pressure FORMCHECKBOX Tuberculosis FORMCHECKBOX Cerebral Palsy FORMCHECKBOX High Cholesterol FORMCHECKBOX Tumors FORMCHECKBOX Chemotherapy FORMCHECKBOX hives/ rash FORMCHECKBOX Ulcers FORMCHECKBOX Chest Pains FORMCHECKBOX hypoglycemia FORMCHECKBOX Venereal Disease FORMCHECKBOX Chemical Dependency FORMCHECKBOX Joint replacement FORMCHECKBOX Yellow Jaundice FORMCHECKBOX Chicken Pox FORMCHECKBOX Kidney Disease FORMCHECKBOX Cold Sores FORMCHECKBOX Leukemia FORMCHECKBOX Circulatory Problems FORMCHECKBOX Liver Problems FORMCHECKBOX Congenital Heart Lesions FORMCHECKBOX Mitral Valve Prolapse FORMCHECKBOX Convulsions FORMCHECKBOX MononucleosisAll Patients: Are you allergic to or have you ever had any reaction to the following? (Check all that apply.) FORMCHECKBOX Aspirin FORMCHECKBOX Codeine FORMCHECKBOX Penicillin FORMCHECKBOX None FORMCHECKBOX Anesthetic – Local FORMCHECKBOX Latex FORMCHECKBOX Sulfa Drugs FORMCHECKBOX Barbiturates FORMCHECKBOX Nitrous Oxide Sedation FORMCHECKBOX Other antibioticsDo you know of any reason why routine dental procedures might pose a risk to you, our staff, or other patients? FORMCHECKBOX Y FORMCHECKBOX N If yes, please describe: FORMTEXT ?????Is there anything important about your medical condition we have not asked? FORMCHECKBOX Y FORMCHECKBOX N If yes, please describe: FORMTEXT ?????medication informationAll Patients: Are you currently taking any of the following? (Check all that apply): FORMCHECKBOX None FORMCHECKBOX Antibiotics/Sulfa Drugs FORMCHECKBOX Insulin FORMCHECKBOX Other (please list ) FORMCHECKBOX Antihistamines/Allergy FORMCHECKBOX Nitroglycerin FORMCHECKBOX Aspirin ( Daily) FORMCHECKBOX Oral Contraceptives FORMCHECKBOX Blood thinners FORMCHECKBOX Osteoporosis Medications FORMCHECKBOX Blood pressure Medication FORMCHECKBOX Other Diabetic Medications FORMCHECKBOX Cancer/Chemo Medications FORMCHECKBOX Recreational Drugs FORMCHECKBOX Cortisone/Steroids FORMCHECKBOX Thyroid Medications FORMCHECKBOX Heart Medication FORMCHECKBOX TranquilizersDrug NameDosageReason Prescribed FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Financial GuidelinesWe are committed to providing you with the best care possible to achieve total oral health. In order to achieve these goals, we need your assistance and your understanding of our financial guidelines. InsuranceWe accept all major dental insurance payments, however we may not be an in network provider for your plan. If we are not an in network provider, review your plan details, as in many cases insurance reimbursement is very similar. We are in network for Delta Dental Premier, Aetna, Metlife, Blue Cross/Blue Shield and United Concordia. We do not participate in any HMO/DMO plans.No estimate is a guarantee of payment. Please understand, you are responsible for all charges not paid by your insurance. Also, many insurance companies are excluding certain dental procedures or downgrading procedures to a lesser reimbursement level; in which case, you would be responsible for the difference.Workers Compensation claims will be filed for you. Please understand the carrier will assign a dollar amount that will be paid towards the claim, which may or may not cover the entire fee. Any amount not covered by the carrier, will be your responsibility.Minors must be accompanied by a parent or legal guardian. If the parents are separated or divorced, the person accompanying the minor will be responsible for copayment at the time of service. PaymentsPatient portion or patient co-pay is due at the time services are rendered - unless prior financial arrangements have been made. Payment Information: All major credit cards are accepted (Visa, MasterCard, Discover)Various financing options with CareCredit? Balances left over 90 days will incur an 18% or $10 minimum monthly finance charge. 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. Short Cancelled/ Missed AppointmentsPlease give 48 hours notice if you are unable to keep your reserved time. Unless an emergency occurs, we expect to run on time for your appointments, and we appreciate the same courtesy from you. Short canceled or missed appointments: There will be a charge of $50 for a standard missed appointment when there was no prior notification. Please note if you missed an appointment for a major restorative appointment, you may be charged a higher fee.By signing below I acknowledge I have read and understand the guidelines above.Signature: FORMTEXT ?????Date: FORMTEXT ?????Patient consent- payment authorization – signature on fileTo the best of my knowledge, all of the preceding answers are correct. If I have any changes in my health status of if my medication changes, I shall inform the dentist and staff at the next appointment without fail.I hereby authorize payment directly to Dr. Olenyn of the dental benefits otherwise payable to me.I hereby authorize Dr. Olenyn to release any information concerning my health or dental care, advice, treatment or supplies provided. This information is to be used in administering dental claims and/or discussing treatment options with other dental professionals.I understand and agree that (regardless of my insurance status) I am ultimately responsible for the balance on my account for any professional services rendered. By signing below, I acknowledge that I have read and understand the statements above. Signature: FORMTEXT ????? Date: FORMTEXT ????? ................
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