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Patient Registration Form.

Welcome to Sweet Tooth Dentistry, your dental home! Our office looks forward to provide you with exceptional dental care. To assist us in serving you better, please complete both sides of the following confidential form.

date

First Name

Last Name

Prefers to be called

Address

City

Postal Code

Date Of Birth

Age

Salutation

Ms. Ms.

Cell Phone

Work Phone

Best Way To Contact

Cell Text Email Home

Best Time To Contact

Morning Evening

Whom May We Thank For Refering You

Google Website Friend Other

Are other family members pt. at our office: N/Y: Name

In Emergency contact

Phone

Family Physician

Ph. No.:

Address

Preferred Appt. time: Morn/ Even.; M/Th/W/Th/F/Sa/Su

ID for prescriptions: Type

No

Financial, Insurance and Credit Information     Name

a).Relationship

Phone No.

Address

Person responsible for account

Self Other
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 the payment at the time of service. We accept the following forms of payment: Cash/ Card/ Insurance Assignment. We do not accept personal cheques. Please provide following information for assignment purposes.
We accept the following forms of payment: Cash/ Card/ Insurance Assignment. We do not accept personal cheques. Please provide following information for assignment purposes.

Primary Dental Insurance

Relationship

DOB

Occupation

Insurance Carrier

Certificate no.

Submission

Assignment Non-Assignment

Signature Required:

Yes No

Secondary Dental Insurance.

Relationship

DOB

Occupation

Insurance Carrier

Certificate no.

Submission

Assignment Non-Assignment

Signature Required:

Yes No

INSURANCE ASSIGNMENT AGREEMENT/ AUTHORIZATION

As a professional courtesy to our most valued patients, we will accept insurance assignment under the following terms and conditions:
  • 1. Any amounts not paid for under your insurance plan and due to our office will be paid by you. Payment is due at the time of service, including any deductibles or co-payments.
  • 2. When your treatment requires laboratory services, a deposit equal to the estimated laboratory fee is required at the time that your dental impressions are taken.
  • 3.While we will do our best to obtain accurate information regarding your eligibility and benefits, in some cases the insurance companies will not provide us with the most up to date information resulting in inaccuracies. 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.
  • 4. If full payment has not been made within 30 days of the claim submission any outstanding balance will be your responsibility should your insurance company deny all, or a portion of your claim. The balance will be charged to your credit card on file and a receipt of any charges will be mailed to you.

I hereby authorize Sweet Tooth Dentistry to process payment to my credit card of any outstanding balance occurred during the course of dental treatment to keep my account current.

Credit card no:

CVV:

Exp. Date:

Name on card:

Signature:

Date:

I have read or have had read to me the office policies and insurance assignment conditions. I understand that I am responsible to pay for all dental fees charged to me for services provided. My signature below is authorization of the assignment of my Dental Insurance payment to Sweet Tooth Dentistry. If my plan denies payment of my benefits to Sweet Tooth Dentistry, I agree to pay my account in full.

Signature of Patient, Parent or Guardian

Date

PLEASE DO NOT HESITATE TO ASK OUR STAFF SHOULD YOU HAVE ANY QUESTION REGARDING ANY POLICY

Your appointment will be reserved especially for you. If you are unable to keep the appointment we will require 48 hours’ notice, otherwise it will be necessary to charge for time lost.

Primary Dental Insurance

Name

Date

Is there an immediate dental problem?

Previous dentist (if any)

Last Dental Visit

Please tick appropriate boxes

1. When was your last cleaning and check-up appointment ?

2. Are any of our teeth sensitive to

Cold Sweet Heat Other

3. Do your gums bleed when

Brushing Flossing Spontaneously

4.Do you suffer from pain and /or swelling of your gums ?

Yes No

5.Are you aware of any loose teeth?

Yes No

6. Feel dry mouth during day

Do you chew gum ? Bite your lips or cheeks regularly? Grind or clench your teeth during the day or night ? Hold any foreign objects with your teeth ? eg. pencils Mouth breathe while awake or asleep ? Bite your nails ?

7. Have you had jaw surgery? ?

Yes No

8.Does your jaw crack or pop when opened widely ?

Yes No

9.Do you have any difficulty in opening or closing your jaw ?

Yes No

10.Have you had any of the following:

Oral Surgery Gum Surgery Braces Other appliances

11.Have you experienced any growth or sore spots in your mouth

Yes No

12.Are you concerned about the appearance of your teeth and if so, what would you like to see changed ? specify:

13.Would you rate your current dental health as:

Excellent Good Fair Poor

14.Is your sugar/snack:

High Medium Low

15.Brushing

Vigorous Light

16. Do you floss regularly: Y/N

17.Cleaning aids presently used:

Floss Stimudents Toothpick Other

18. Do you have any emotional concerns regarding you dental visit ?

Fear Time Money Pain Other

19. Do you have, or have you ever had any of the following? (Check all that apply): None

Dental History
Angina, Chest Pain Bulimia Infective endocarditis Rheumatic Feverr
Shortness of Breath Cancer/Malignancy Heart Attack Sinus Problems
AIDS/HIV Cerebral Palsy Heart Disease Stroke
Anemia DruGg Dependency Heart Murmur Thyroid Condition
Artificial Heart Valve Alcohol Dependency Hepatitis Tuberculosis
Artificial Joints Diabetes High Blood Pressure Stomach Ulcers
Arthritis Dizziness/Fainting Kidney Disease Osteoporosis Medication
Asthma Epilepsy/Seizures Liver Problems Psychiatric Treatment
Bleeding Disorder Hearing Problem Pacemaker Psychiatric Treatment
Implant/Transplant Respiratory/ Lung Disease

1. Are you presently under the care of a physician?

Yes No

2. Have you had a medical examination in the last years ?

Yes No

3. Have you been hospitalized for any Illness or surgery?

Yes No

4. Do you use any prescription or non-prescription drugs?

Yes No
Please List:

5. Have you been warned against taking any medication?

Yes No
Please List and Describe:

6. Do you have any allergies?

Yes No

7. Have you had any radiation or chemotherapy treatment ?

Yes No

8. Have you had any injury or surgery to your face or jaw ?

Yes No

9. Do you have frequent / severe headaches?

Yes No

10. Do you bruise or bleed abnormally ?

Yes No

11. Are there any disease or medical condition that runs in the family?(Like Diabetes, High blood pressure, Cancer, etc.)

Yes No

12. Are there any disease or medical condition that runs in the family?(Like Diabetes, High blood pressure, Cancer, etc.)

Yes No

13. Have you ever fainted?

Yes No

14. Have you ever had any heart condition?

Yes No

15. Have you had any recent change to your health?

Yes No

16. Are there any disease or medical condition that runs in the family?

Yes No

16. Are there any disease or medical condition that runs in the family?

Yes No

17. Is there anything about yourself we should be made aware of?

Yes No

Explain:

18. Do you smoke?

Yes No

19 Have you ever smoked?

Yes No

years

/day

21. Women: Pregnancy

Yes No

22. OCP

Yes No

23. Breastfeeding

Yes No

I understand that the information that I have given today is correct to the best of my knowledge and haven’t omitted any information. I also understand that it is my responsibility to inform this office of any changes in my medical status. I have had the opportunity to ask questions and I also consent my physician being contacted if necessary. I hereby authorize the dentist or designated staff to perform diagnostic, dental and oral surgery procedures and services.
Notes:

Notes:

Patient/ Parent's (Guardian) Signature:

Date

Dentist: