Patient Registration Form Patient InformationName Mr.Mrs.MissMs.Dr.Child Prefix First Last Gender Male Female Birth Date MM slash DD slash YYYY AgeSoc. Sec. #Email Address Street Address City AlabamaAlaskaAmerican 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 Code Home #Cell#Have you ever been a patient of our practice? Yes No Referred By:Has a family member ever been a patient of our practice? Yes No In case of emergency please contact - Name:PhoneEmployer Bus. Ph.Relationship:PERSON RESPONSIBLE FOR ACCOUNT Self (If self, skip this section) Spouse Father Mother Other Relationship:Name:S.S.#Birth Date: MM slash DD slash YYYY AgePh#Address Street Address City AlabamaAlaskaAmerican 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 Code Email Employer Bus. Ph#SPOUSE OR SIGNIFICANT OTHERS INFORMATION ( IF DIFFERENT THAN ABOVE) NameRelationS.S.#Birth Date MM slash DD slash YYYY Address Street Address City AlabamaAlaskaAmerican 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 Code Email Ph#Employer Bus. Ph#INSURANCE INFORMATION Please answer questions below for patientStudent: Yes No StatusFull TimePart TimeMarital Status:MarriedDivorcedWidowSingleSchool Name -City-StateEmployed: Yes No StatusFull TimePart TimeRetiredNotDENTAL INSURANCE PLAN INFORMATION Do You have Dental Insurance? Yes No Section BreakEmployerBus. Ph #Bus. AddressIns. Co. NameTel.#Address Street Address City AlabamaAlaskaAmerican 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 Code Group#Policy Holders NameSex Male Female ID #Policy Holders ph#Email Date of birth of Policy Holder MM slash DD slash YYYY SS #Relationship to patient:DENTAL INFORMATION Reason for today’s visit:Are you in pain? Yes No For How LongPlease indicate any of the following problems by checking off the corresponding box: Discomfort, clicking, or popping in jaw Lost / broken filling(s) Stained teeth Difficulty closing jaw Red, swollen, or bleeding gums Gum disease Locking jaw Difficulty opening jaw Do you have or use a dental appliance Ringing in ears Bad breath Loose / shifting teeth Blisters/sores in or around the mouth Burning tongue / lips Toothache Broken / chipped tooth Recent infections or sore throat Teeth grinding / clenching Are you prone to cold sores Swelling / lumps in mouth Prolonged bleeding from an injury / extraction Food caught between teeth None of the above Are your teeth are sensitive to: Hot Cold Sweets Biting Last dental exam MM slash DD slash YYYY Last dental x–rays MM slash DD slash YYYY Times a day you brush?Times a week you floss?How would you rate your smile?--select--1 (Worst)2345678910(Best)Would you like whiter teeth? Yes No What type of toothbrush bristles do you use?--select--SoftMediumHardNot sureMEDICAL INFORMATION Are you in good health? Yes No Are you under the care of a physician? Yes No Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment? Yes No Have you had any illness, operations, or been hospitalized in the past five years? Yes No What for:Date MM slash DD slash YYYY Do you have, or have you had, any of the following diseases, medical conditions, or procedures? Please check all that apply High blood pressure Low blood pressure Mitral valve prolapse Heart murmur Rheumatic fever Chest pain / Angina Heart attack(s) Irregular heart beat Pacemaker Heart surgery Damaged heart valve Pneumonia / Bronchitis / Chronic cough Chronic fatigue / Night sweats Trouble climbing 1-2 flights of stairs Anemia HIV / AIDS Mental health problems Problems with immune system (possibly from med./surg.) Delay in healing Hay fever / Sinus problems Snoring Sleep apnea / CPAP Respiratory problems Tuberculosis Emphysema Asthma Do you smoke Do you use chewing tobacco A history of drug or alcohol abuse A history anorexia/bulimia Abnormal bleeding Bleeding tendency Blood transfusion Blood disorder Bruise easily Eye disease /Glaucoma Jaundice /Liver disease Hepatitis Gallbladder trouble Fainting spells Convulsions / Epilepsy Stroke Thyroid trouble Diabetes Are you on dialysis Kidney trouble Contagious diseases Infectious mononucleosis Low blood sugar Swollen ankles Arthritis /Joint disease Prosthetic implant Joint replacement Stomach ulcers Osteonecrosis Osteoporosis /Osteopenia Tumor or growth Cancer / Radiation / Chemotherapy MEDICATION & ALLERGIESAre you now taking: Blood thinners (Coumadin, Plavix, Aspirin, etc...) Are you taking, or have you ever taken, any bone density meds. or bisphosphonates, such as Fosamax, Boniva, Actonel, IV Zometa, Reclast, Xgeva, Prolia, or Aredia within the past 12 years. If yes, please check off Are you allergic to, or had a reaction to: Penicillin Lidocaine or other anesthetic Amoxicillin Codeine or other narcotics Latex Please list any other medication or antibiotic you are allergic to:Please list any allergies other than drug allergies:Please list any medication(s) you are taking (including natural, herbal, or homeopathic products)MedicationDosageFrequency Please type below any other information you would like the Dentist to be aware of:Questions below for women only Women please note: antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician/gynecologist for assistance regarding additional methods of birth control. 1) Is there a possibility of pregnancy? Yes No 2) Expected delivery date: MM slash DD slash YYYY 3) Are you nursing? Yes No 4) Are you taking birth control pills: Yes No I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any member of the staff responsible for any errors or omissions that I have made in the completion of this form. I agree that all information I provided is true and correctSignature of patient (Parent or Guardian of Minor)Date MM slash DD slash YYYY If you do have dental/medical insurance we will gladly submit you treatment/charges to you insurance company. However, it is your responsibility to complete the identifying information on this form and keep us updated with any insurance changes. Some insurance companies pay fixed allowances for procedures and other pay a percentage of the charges. It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid by your insurance company. This signature on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment to Dr. Craig H. Etts and any of his Associate Dentists otherwise payable to me. A photocopy of this assignment shall be considered as effective and valid as the originalSignature of patient (Parent or Guardian of Minor)Date MM slash DD slash YYYY If the insurance company sends payment directly to me I agree to endorse the back of the check over to Dr. Craig H. Etts and mail or deliver to the office towards payment of treatment rendered.Signature of patient (Parent or Guardian of Minor)Date MM slash DD slash YYYY Release of Information & Consent for Treatment All information provided herein is true and correct. I wish to receive treatment at the dental office of Dr. Craig H. Etts. I permit his staff and all other persons caring for me to treatment in ways they judge are beneficial to me. I understand that this care can include an evaluation, testing and treatment. No guarantees have been made to me about the outcome of this care. I give permission to Dr. Craig H. Etts and his staff and associates to release information, verbal and written, contained in my dental record and other related information, to my insurance company, and all other persons as it related to my treatment. I understand that this information is sometimes sent via mail, email and fax This signature authorizes Dr. Craig H. Etts and his staff and associates to obtain/or release dental records and/or professional information from my Dentist or other medical professional as it relates to my treatment.Signature of patient (Parent or Guardian of Minor)Date MM slash DD slash YYYY Notice of Privacy Practices (HIPAA Acknowledgement/Consent) I hereby acknowledge that a copy of this office’s Notice of Privacy Practices has been made available to me. In addition, I hereby consent to the use and disclosure of my personal health information for the purpose of treatment, payment and health care operations.Signature of patient (Parent or Guardian of Minor)Date MM slash DD slash YYYY I agree to pay C. H. Etts, DDS, PA for the services provided to me or my dependants. If any insurance carrier requires additional information I will cooperate and assist in the provision of information, authorizations, releases, or any other type of information necessary to allow for speedy collection from my third-party payer. I acknowledge responsibility for any and all account balances. I understand that if I default on payment of my account balance, that my account can be turned over to a collection service and I can be charged, interest, late fees, attorney fees, including costs of a collection agency and associated fees if turned over to an agency and court costs in addition to the remaining balance that is due. In an effort to contain the ever-rising costs of healthcare our office charges a rebilling fee on unpaid balance over sixty (60) days old at the rate of 1.5% (18% per annum). Also for patients needing a payment plan a $25 late fee will be assessed on payments not received by the last day of each month. We feel this will help offset the costs of rebilling patient thus preventing the need to raise fees on all dental services. I also understand that I can be assessed a $75 no-show or late cancellation fee for appointments that I fail to show-up to or did not give a 48 hour cancellation notice. I further understand that this agreement is binding regardless of any legal transaction currently in progress or initiated during or after the course of my treatments unless agreed to in writing by myself and a representative of C. H. Etts, DDS, PA, and/or its affiliate or subsidiaries.Signature of patient (Parent or Guardian of Minor)Date MM slash DD slash YYYY CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
