Download Patient Registration Form - Treasure Coast Endodontics

WELCOME
ABOUT YOU
Today’s Date: _____/______/______
File #: __________
INSURANCE INFO
Patient Name: _______________________________________
LAST
FIRST
MI
What You Prefer To Be Called: ____________
Male
Female
Primary Dental Insurance
Birth date: _____/_____/_____ Age: _____ SS#: ____________
Co. Name: _________________________________________
Mailing Address: ______________________________________
Address: ___________________________________________
____________________________________________________
___________________________________________________
CITY
STATE
CITY
ZIP
STATE
ZIP
Home Phone #: _______________________________________
Phone #: ___________________________________________
Work Phone #: _______________________ Ext: ____________
Insured’s SS#: ______________________________________
Other Phone #s: ______________________________________
Group # (Plan, Local, or Policy #): _______________________
E-mail Address: ______________________________________
Insured’s Name: _____________________________________
Referred By: _________________________________________
Relation: __________________ Date of Birth: ____/____/____
Employer: _____________________ How Long? ___________
Insured’s Employer: __________________________________
Employer’s Address: ___________________________________
____________________________________________________
CITY
STATE
Secondary Dental Insurance
Co. Name: _________________________________________
ZIP
Occupation: __________________________________________
Address: ___________________________________________
Status:
__________________________________________________
Minor
Single
Married
Divorced
Separated
Widowed
Spouse’s Name: ______________________________________
Do you have children?
Yes
No
How many? _____
CITY
STATE
ZIP
Phone #: ___________________________________________
Insured’s SS#: ______________________________________
Group # (Plan, Local, or Policy #): _______________________
ACCOUNT INFO
Insured’s Name: _____________________________________
Relation: __________________ Date of Birth: ____/____/____
Insured’s Employer: __________________________________
Person ultimately responsible for account
Name: _______________________________________
Relation: _____________________________________
Billing Address: ________________________________
IN EVENT OF EMERGENCY
_____________________________________________
CITY
STATE
Whom should we contact? _________________________________
ZIP
SS#: _________________________________________
Relation: ________________________________________________
Drivers License #: ______________________________
Home Phone #: ___________________________________________
Work Phone #: _________________________________
Work Phone #: ___________________________________________
Payment method:
Who is your Medical Doctor? ________________________________
Cash
Check
________________________________ / ____________
M.D.’s Phone #: __________________________________________
Credit Card - Enter card # above (if accepted)
______ (INITIAL) I hereby authorize assignment of my
insurance rights and benefits directly to the provider
for services rendered. I fully understand I am solely
responsible for any balance not paid by my
insurance company (if offered at this office).
PLEASE CONTINUE
DENTAL INFO
Reason for today’s visit:
Consultation
Emergency
Are you in pain?
No Yes, How Long? ______________________
Please indicate
any of the following problems:
Discomfort, clicking or popping in jaw
Lost/broken Filling(s)
Stained tooth
Red, swollen or bleeding gums
Teeth grinding
Locking jaw
Sensitive tooth, teeth or gums
Ringing in ears
Bad breath
Blisters/Sores in or around the mouth
Broken/Chipped tooth
Other: ____________________
Do you require pre-medication?
Yes No Don’t know
Dentist: ______________________________________________________________ (_______) _____________________________
Name
Phone#
MEDICAL HISTORY
Have you taken any medication or drugs during the past two years?………………………………………….……..Yes
No
Are you taking any medication, drugs or pills now?………………………………………………………………….….Yes No
If yes, please list name and dosage: __________________________________________________________
Have you ever taken the diet pills Fen-Phen, Pondiman, or Redux for weight loss? ……………………………… Yes No
Are you aware of having an allergic (or adverse) reaction to any medication or substance?…………………..…Yes No
If yes, please list: _________________________________________________________________________
Have you been a patient in the hospital during the past five years?………………………………………………..….Yes No
Indicate which of the following you have had or have at present. Check “yes” or “no” to each item:
Heart (Surgery, Disease, Attack) Yes No
Ulcers……………. Yes No
Hepatitis A, B, C……………… Yes No
Chest Pain……………………..… Yes No
Diabetes………… Yes No
Venereal Disease……….……. Yes No
Congenital Heart Disease…….... Yes No
Thyroid Problems
Yes No
A.I.D.S…………………………. Yes No
Heart Murmur……………………. Yes No
Glaucoma…….…. Yes No
H.I.V. Positive…………………. Yes No
High Blood Pressure……………. Yes No
Contact Lenses… Yes No
Cold Sores/Fever Blisters…… Yes No
Mitral Valve Prolapse………….... Yes No
Emphysema……. Yes No
Blood Transfusion……………. Yes No
Artificial Heart Valve………….…. Yes No
Chronic Cough…. Yes No
Hemophilia………………….…. Yes No
Heart Pacemaker……...………... Yes No
Tuberculosis……. Yes No
Sickle Cell Disease…………… Yes No
Rheumatic Fever…………...…… Yes No
Asthma………….. Yes No
Bruise Easily………………….. Yes No
Arthritis/Rheumatism……………. Yes No
Hay Fever………. Yes No
Liver Disease…………………. Yes No
Cortisone Medicine……………… Yes No
Latex Sensitivity..
Yes No
Yellow Jaundice………………. Yes No
Swollen Ankles………...….…….. Yes No
Allergies or Hives
Yes No
Neurological Disorders………. Yes No
Stroke…………………………….. Yes No
Sinus Trouble…..
Yes No
Epilepsy or Seizures…………. Yes No
Diet (Special/Restricted)…...…... Yes No
RadiationTherapy Yes No
Fainting or Dizzy Spells……… Yes No
Artificial Joints (hip, knee, etc.)… Yes No
Chemotherapy….. Yes No
Nervous/Anxious……………… Yes No
Kidney Trouble…………………... Yes No
Tumors………….. Yes No
Psychiatric/PsychologicalCare Yes No
Do you use more than two pillows to sleep?………………………………………………………………………………Yes No
Have you lost or gained more than 10 pounds in the past year?……………………………………………………….Yes No
Do you have or have you had any disease, condition, or problem not listed?……………………………………...…Yes No
If yes, please list: _____________________________________________________________________________________________
Women: Are you: Pregnant? Yes
Months_______ No
Nursing? Yes
No
Taking birth control pills? Yes
No
AUTHORIZATION
We invite you to discuss with us any questions regarding our services. The best dental health services are based on a friendly,
mutual understanding between provider and patient.
Our policy requires payment in full for all services rendered at the time of visit, unless other arrangements have been made
with the business manager. If account is not paid within 90 days of the date of service and no financial arrangements have
been made, you will be responsible for legal fees, collection agency fees, interest charges and any other expenses incurred in
collecting your account.
I authorize the staff to perform any necessary services needed during diagnosis and treatment. I also authorize the provider to
release any information required to process insurance claims.
I understand the above information and guarantee this form was completed correctly and to the best of my knowledge, and
understand it is my responsibility to inform this office of any changes to the information I have provided.
Update
Signature__________________________________________ Date_______/_______/______
______ __/__/__
Adult Patient
Parent or Guardian
Spouse
Initials
Date
______ __/__/__
Presented by _______________________________________ Date______/_______/______
Initials
PLEASE CONTINUE
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FINANCIAL INFO
ABOUT FINANCIAL ARRANGEMENTS, THIRD PARTY PAYMENTAND DENTAL INSURANCE
Payment or co-payment for services is due at the time services are rendered. We accept cash, checks, credit cards, and bank debit cards. We have
contracted to accept Visa, Master Card, American Express, and Discover. We will be glad to help you process your insurance claim form for your
reimbursement. Provided you give us the proper information the dental insurance form will be ready by the time treatment is completed. Your
understanding about the following information is important to us:
Your insurance or third party contract arrangement is between you, your employer and the insurance company. We may not be a contracted
provider for your plan.
Not all services are covered benefits in all contracts. Some insurance companies arbitrarily select certain services they will not cover.
Promptness in processing your claim varies from one insurance company to another; it may take 30-60 days to process your dental claim.
We have set fees for each procedure, unless we are a contracted provider for your plan. Perhaps the most misunderstood part of your
coverage is known as the usual customary and reasonable (UCR) charges. The UCR is the maximum fee that your policy will cover. This dollar
figure varies with each dental policy and is determined in large part by the amount of coverage purchased by your employer. Stated simply, the
lower the UCR, the more your out- of- pocket expense for dental care. That is why following your initial call to this office; we encouraged you to
check with your insurance company.
We must emphasize that as dental care providers, our relationship is with you, not your insurance company. While filing of insurance claim
forms is a courtesy that we extend to our patients, all charges are your responsibility from the date services are rendered.
If you have any questions about the above information, please do not hesitate to ask us. We are here to help.
Patient’s signature ________________________________________ Date______/______/______
Adult Patient
Parent or Guardian
Spouse
CONSENT FOR ENDODONTIC THERAPY
Endodontic (root canal) therapy is a commonly performed and generally safe dental procedure to save a tooth, which might otherwise
need to be removed. We would like our patients to be informed about the procedure, the possible risks and alternative treatment options.
RISKS: The risks of treatment include (but are not limited to) complications resulting from the use of dental instruments and materials,
drugs, sedation medicines, analgesics, anesthetics and injections. These may include pain, facial swelling, or bruising, bleeding, postoperative infection, which could require hospitalization, reaction to anesthetics, jaw muscle pain and spasms, temperomandibular joint
(TMJ) problems, jaw fracture, numbness or tingling of the lip, chin, tongue, gums, cheeks or teeth (which is generally temporary but can
in rare instances be permanent), sinus perforation or inflammation, allergic reactions, injury to the mouth or eyes, alterations of taste,
changes in occlusion (bite), and loss of teeth, which could require hospitalization.
RISKS MORE SPECIFIC TO ENDODONTIC THERAPY: Include the possibility of instruments being dislodged inside the tooth,
perforation (unintended holes), fracture or loosening of the tooth which may lead to its loss, damage to crowns, bridges, veneers, or
existing fillings. During treatment unanticipated complications may be discovered which make a successful outcome less likely or
impossible, or which may require dental surgery to correct. These may include blockages of the canals due to fillings or prior treatment,
natural blockages (calcifications), broken instruments, severely curved or narrow root canals, periodontal (gum) defects requiring followup periodontal therapy, or fractured teeth.
PRESCRIBED MEDICATIONS: May cause allergic reactions, nausea, vomiting, diarrhea, or gastrointestinal problems requiring
medical treatment. Pain medications can cause drowsiness or lack of awareness or coordination, which may be influenced by the use of
alcohol, tranquilizers, sedatives and other drugs. It is advisable not to operate a motor vehicle or dangerous device while taking these
medications. Prescription drugs may interact or interfere with other drugs you are taking, such as cholesterol reducing medications and
birth control pills.
OTHER TREATMENT CHOICES: As an alternative to root canal therapy, you may decide to have the tooth extracted, wait for more
definitive symptoms to develop, or choose no treatment. Extraction and no treatment also pose risks, which may include pain, swelling,
spread of infection, and/or loss of teeth.
CONSENT: My signature below constitutes my acknowledgment that I have read the above carefully and consent to the procedure(s)
deemed necessary or advisable by the doctors of Treasure Coast Endodontics. I understand that root canal therapy is not always
successful and on occasion a tooth, which has had root canal therapy, may require re-treatment, surgery or extraction. I also
understand that upon completion of treatment, I must return to my general dentist for permanent restoration of my tooth.
Patient’s Name (please print) __________________________________________________________
Patient’s Signature __________________________________________ Date_______/_______/_____
Adult Patient
Parent or Guardian
Spouse
Presented by _______________________________________________ Date_______/_______/_____
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