NEW PATIENT REGISTRATION

Name*

First NameLast Name

Date of Birth*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone Number*

Area CodePhone Number

Home Phone Number

Area CodePhone Number

Email*

example@example.com

Where did you hear about Miller Dental Arts?*

Please provide us with the name of the friend or family member (Optional)

Which Miller Dental Arts Location would you like your appointment to be scheduled?*

West New York, New JerseyFort Lee, New Jersey

Name

First NameLast Name

Phone Number

Area CodePhone Number

Relationship to Patient

Do you have dental insurance?*

YesNo

Driver’s License Number

Social Security Number

What type of Primary Dental Insurance do you have?*

What is your Employers Name?*

Name of Insured (Primary Insurance)*

Date of Birth (Primary Insurance)*

Date

ID Number (Primary Insurance)*

Group Number (Primary Insurance)

OPTIONAL (Take a Photo of the front of your insurance card)

Browse Files

OPTIONAL (Take a Photo of the back of your Insurance card

Browse Files

Do you have Secondary Dental Insurance?*

YesNo

Name of Insured (Secondary Insurance)

Date of Birth (Secondary Insurance)

Date

ID Number (Secondary Insurance)

Group Number (Secondary Insurance)

Are you under the care of a physician?

YesNo

If yes, include name, address, phone number and reason.

Do you have any allergies?*

YesNo

Which of the following are you allergic to?*

Are You currently taking any Medications?

YesNo

Please list all prescription and over the counter medications including name, dosage, and purpose.

Are you in good health?

YesNo

Have there been any changes in your health in the past year?

YesNo

If yes, please explain.

Date of last physical exam?

Have you been hospitalized in the past 5 years?

YesNo

If yes, list reason and date.

Do you use controlled substances (drugs)?

YesNo

If yes, which ones?

Do you use tobacco?

YesNo

If yes, what kind, how often.

Do you drink alcohol?

YesNo

If yes, how many drinks in last 24 hours? How many per week?

Have you had an orthopedic total joint (hip, knee, elbow, finger, etc) replacement?

YesNo

If yes, include date, type of replacement and any complications.

Are you taking or planning to take an antiresorptive agent (such as Fosamax, Actonel, Boniva, Reclast, and Prolia)?

YesNo

If yes, what type, dosage and when was it taken?

Since 2001, have you or will you be treated with an antiresorptive agent (Aredia, Zometa, XGEVA)?

YesNo

If yes, what type, dosage and when was it taken?

For which condition?

Are you?

Taking birth control or hormone replacementNursingPregnant or trying to get pregnant

If yes to any please specify type and reaction.

Please indicate if you have or have had any of the following diseases or problems.

If you have any medical conditions listed above, please describe:

Please check any of the following conditions apply to you:

Artificial (prosthetic) valvePrevious infective endocarditisDamaged valves in transplanted heartCHD; unrepaired cyanotic CHDCHD; repaired completely in last 6 monthsCHD; repaired with residual defects

Do you take Antibiotics prior to a dental visit?

YesNo

If yes, please explain why you take antibiotics prior to dental visits:

Do you have any diseases or problems not listed above that you think I should know about?

YesNo

If yes, what?

Is there anything you would like the Dentist or Hygienist know prior to your first visit?

Do you grind your teeth? (Currently or in the past)

YesNo

Bite your cheek?

PresentPastNever

Tongue thrust?

PresentPastNever

Mouth breather?

PresentPastNever

Bulimic/ anorexic?

PresentPastNever

Cigar/cigarette or any tobacco products

PresentPastNever

Pipe?

PresentPastNever

Bite nails?

PresentPastNever

Smokeless tobacco?

PresentPastNever

Suck your thumb/finger?

PresentPastNever

Use a toothpick or stimulator?

PresentPastNever

Use chewing gum?

PresentPastNeverType option 4

Eat candy?

PresentPastNever

Drink soft drinks?

PresentPastNever

If present or past to any, please list when, how often and what kind if applicable.

How often do you brush? When?

How often do you floss? When?

Do you use mouthwash? What type?

Other types of oral health instruments?

Personal or family history of oral cancers?

YesNoOther

Are you currently experiencing pain in your mouth?

YesNo

If yes, where at, what type and for how long?

Have you ever had orthodontic treatment (braces or Invisalign)?

YesNo

Have you had a bite plate / guard?

PresentPastNever

Have you had a "Deep cleaning?" ("Scaling and Root Planing?)

YesNoOther

Have you had oral surgery?

PresentPastNever

Have you had a serious injury to your mouth or head?

YesNo

If yes, please describe the injury with, dates, and reasons.

Date of last dental appointment?

Welcome to Miller Dental Arts:

The following statement of our office policy is intended for your information. We want to keep our patients aware of all our office procedures.

Appointments: Please give us at least 48 hours notice if you must cancel an appointment. This way we can offer the time to another patient. If you cancel an appointment with less than 24 hours notice, or fail to appear for your scheduled time, there will be a $50 charge. Please remember that the purpose of a "missed appointment" fee is to encourage a sense of responsibility for our time, and is not intended to recover most or all of the fees for the planned but "missed" procedure. Conversely, we have the respect for your time and we try to see all of our patients on schedule.

Sterilization: be assured that our primary concern is for your health and safety. All of our instruments and handpieces are heat sterilized. We are in compliance with all OSHA and New Jersey state regulations.

Fees and Insurances: Our office provides quality personalized care. The doctor/patient relationship is precious. No third-party should interfere with this relationship. An insurance company should not dictate treatment. Regardless of your coverage, we will suggest the best care that is appropriate for you. You will be involved in the treatment planning process.

Ultimately, you are financially responsible for the cost of this care, even if we participate in your insurance plan. Any services that are not covered by your insurance are your responsibility. If we do not participate with your insurance plan, he will pay Miller Dental Arts and your insurance company will reimburse you to the extent of your coverage. All insurance plans are different, it is the patients responsibility to know and understand his/her own plan.

If your insurance benefits have been predetermined prior to treatment, we will wait 60 days for the insurance payments to come directly to us. the patient must pay all co-payments at the time of treatment.

After 60 days from the time of service, all balances must be paid in full if your insurance company has not done so. Your insurance company is a third-party payer and responsible only to the insured. Therefore, you must take an active role in seeing that your insurance company pays Miller Dental Arts before the 60 day elapsed. Should this result in an overpayment, the doctor will refund it to you.

Major treatment: all crown and bridge work requires a minimum down payment of 50% at the first treatment appointment. The balance must be completely paid when the case is complete.

Payment plan: we offer a payment plan for dental treatment involving several office visits as follows:

A minimum payment of 50% is due at the first visit. The balance, which includes payment charges of 18% per year on an unpaid balance, will be paid when the case is complete.

Method of Payment: all payments can be made by Cash, ApplePay, Visa, MasterCard, or AMEX. Personal Checks are accepted on a case-by-case basis, and a $50 charge will be imposed for returned checks. We also participate with Care Credit. Arrangements for financing a course of treatment can be made through them.

Please read and sign the agreement below. If you have any questions, we will be happy to answer them.

I hereby authorize and guarantee payments for all services rendered. I agreed to pay any amount my insurance company does not or will not pay. I agree to pay a late charge of 18% per year on any balance 30 days past due as well as collection cost, court costs, attorney fees and interest fees accrued with the collection of this account. I have been given a copy of this agreement.

Date

Signature

New Patient Registration

Emergency Contact Info

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Medical History

Dental History