Patient Forms2

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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

SalutationMs.Mr.Mrs.

Cell Phone

Cell Phone

Work Phone

Best Way To ContactCellTextEmailHome
Best Time To ContactMorningEvening

Whom May We Thank For Refering YouGoogleWebsiteFriendOther

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

In Emergency contact

Phone

Family Physician

Address

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

ID for prescriptions: Type

No.

Financial, Insurance and Credit Information

Person responsible for accountSelfOther

Name

Relationship

Phone No.

Address

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
AssignmentNon-Assignment
Signature Required:
YesNo

Secondary Dental Insurance.

Relationship

DOB

Occupation

Insurance Carrier

Certificate no.

Submission AssignmentNon-Assignment
Signature Required:
YesNo

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.

Dental History
Name: _________________ Date____________

Is there an immediate dental problem? _________________

Previous dentist (if any) ___________Last Dental Visit________________

Please tick appropriate boxes

13.Are you concerned about the appearance of your teeth and if so, what would you like to see changed ? specify:
2. Are any of our teeth sensitive to ColdSweetHeatOther

3. Do your gums bleed when
BrushingFlossingSpontaneously
4.Do you suffer from pain and /or swelling of your gums ?
YesNo
5.Are you aware of any loose teeth?
YesNo
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. pencilsMouth breathe while awake or asleep ?Bite your nails ?

7. Have you had jaw surgery? ?
YesNo
8.Does your jaw crack or pop when opened widely ?
YesNo
9.Do you have any difficulty in opening or closing your jaw ?
YesNo
10.Have you had any of the following:
Oral SurgeryGum SurgeryBracesOther appliances
11.Have you experienced any growth or sore spots in your mouth
YesNo
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:
ExcellentGoodFairPoor

14.Is your sugar/snack:
HighMediumLow

15.Brushing:

VigorousLight

Do you floss regularly: Y/N

16.Cleaning aids presently used:
FlossStimudentsToothpickOther

17. Do you have any emotional concerns regarding you dental visit ?
FearTimeMoneyPainOther

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

Medical History

Angina, Chest Pain
Shortness of Breath
AIDS/HIV
Anemia
Artificial Heart Valve
Artificial Joints
Arthritis
Asthma
Bleeding Disorder

Bulimia
Cancer/Malignancy
Cerebral Palsy
DruGg Dependency
Alcohol Dependency
checkbox Diabetes "Diabetes"]
Dizziness/Fainting
Epilepsy/Seizures
Hearing Problem
Implant/Transplant

Infective endocarditis
Heart Attack
Heart Disease

Heart Murmur
Hepatitis
High Blood Pressure
Kidney Disease
Liver Problems
Pacemaker

Respiratory/ Lung Disease

Rheumatic Feverr
Sinus Problems

Stroke
Thyroid Condition
Tuberculosis
Stomach Ulcers
Osteoporosis Medication
Psychiatric Treatment
Psychiatric Treatment

1. Are you presently under the care of a physician?
YesNo
2. Have you had a medical examination in the last years ?
YesNo
3. Have you been hospitalized for any Illness or surgery?
YesNo
4. Do you use any prescription or non-prescription drugs?
YesNo
Please List:
5. Have you been warned against taking any medication?
YesNo
Please List and Describe:
6. Do you have any allergies?
YesNo
7. Have you had any radiation or chemotherapy treatment ?
YesNo
8. Have you had any injury or surgery to your face or jaw ?
YesNo

9. Do you have frequent / severe headaches?
YesNo

10. Do you bruise or bleed abnormally ?
YesNo
11. Are there any disease or medical condition that runs in the family?(Like Diabetes, High blood pressure, Cancer, etc.)
YesNo

12. Are there any disease or medical condition that runs in the family?(Like Diabetes, High blood pressure, Cancer, etc.)
YesNo
13. Have you ever fainted?
YesNo
14. Have you ever had any heart condition?
YesNo
15. 44. Have you had any recent change to your health?
YesNo
16. Are there any disease or medical condition that runs in the family?
YesNo
If yes, please describe:
17. Is there anything about yourself we should be made aware of?
YesNo
Explain:
18. Do you smoke?
YesNo
Have you ever smoked?
YesNo
years
/day

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:

Patient/ Parent’s (Guardian) Signature: _______________ Date____________ Dentist________________