planotopdental.com-PATIENT REGISTRATION- English

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TODAY'S DATE

MonthDayYear
PATIENT REGISTRATION
PATIENT INFORMATION
Name

First NameMiddle NameLast Name
Nick Name or Preferred Name
Email
example@example.com
Birth Date

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Select which apply:

MaleFemaleSingleMarried
Social Security Number

Contact Detail

	Preferred	Number
Home Phone
Work Phone
Cell Phone

IF PATIENT IS A MINOR, PROVIDE THE FOLLOWING
Parent/Legal Guardian Name

First NameLast Name
Relationship to patient

ParentGrand ParentLegal Guardian
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Same as above

Contact Detail

	Preferred	Number
Home Phone
Work Phone
Cell Phone

With whom does the child reside?

MotherFatherBoth
Social Security Number
EMERGENCY CONTACT INFORMATION
Emergency contact person

First NameLast Name
Phone Number

Area CodePhone Number
Relationship
Name of closest relative not living with you

First NameLast Name
Phone Number

Area CodePhone Number
Relationship
THE BIGGEST COMPLIMENT OUR PATIENTS CAN GIVE US IS THE REFERRAL OF FAMILY & FRIENDS
Whom may we thank for referring you? Please provide full name

First NameLast Name
Are they Patient Here?

YesNo
How did you hear about our office?

Our websiteBuilding SignYour EmployerMailer/ Union HallPublic EventInsurance CompanyOnline SearchSocial MediaDental Center Employee
IF YOU HAVE DENTTAL INSURANCE, PLEASE PROVIDE THE FOLLOWING & YOUR INSURANCE CARD
PRIMARY CARRIER
Insurance Company Name
Insurance Phone

Area CodePhone Number
Employer Name

First NameLast Name
Employer Phone

Area CodePhone Number
Primary Insured Name
Birth Date

MonthDayYear
Relationship to Patient
Insured Insurance I.D.Number
Group Number
Insured Social Security
If student, College Name

Full TimePart Time
SECONDARY CARRIER
Insurance Company Name
Insurance Phone

Area CodePhone Number
Employer Name

First NameLast Name
Employer Phone

Area CodePhone Number
Primary Insured Name
Birth Date

MonthDayYear
Relationship to Patient
Insured Insurance I.D.Number
Group Number
Insured Social Security
If student, College Name

Full TimePart Time

PATIENT REGISTRATION
ACKNOWLEDGEMENT & CONSENT

Acknowledgement of Insurance Payment Authorization: I hereby authorize and direct payment of the dental insurance benefits otherwise payable to me for services rendered, directly to Plano Top Dental. In the event that the insurance company misdirects payment to me, I understand that I am responsible to immediately remit such payments to Plano Top Dental.

Acknowledgement of Financial Responsibility: 1 agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that payment is due at the time of service unless other arrangements have been made. In the event payments are not received by agreed upon dates, I understand that either a 1-42% late charge (18% APR) or a $15 late charge per late payment may be added to my account. I further agree to inform Access Dental/Blue Hills Dental of any address or phone number change within 30 days of such a change. In the event I fail to do so I authorize Plano Top Dental to use all due means, including the use of credit history records, to ascertain my new address for billing purposes.

Notice of Privacy Practices: I acknowledge that I have received the practice’s Notice of Privacy Practices, which describes the ways in which the practice may use and disclose my healthcare information for its treatment, payment, healthcare operations and other described and permitted uses and disclosures, I understand that I may contact the Privacy Officer designated on the notice if I have a question or complaint. To the extent permitted by law, I consent to the use and disclosure of my information for the purposes described in the practice’s Notice of Privacy Practices.

Acknowledgment of Dental Materials Fact Sheet: I acknowledge that I have received and read the Dental Materials Fact Sheet prior to starting restorative dental work at Plano Top Dental.
PATIENT SIGNATURE

Clear
Date

MonthDayYear
PARENT/RESPONSIBLE PARTY SIGNATURE

Clear
Date

MonthDayYear
RELATIONSHIP TO PATIENT

DENTAL HISTORY
Patient Name

First NameLast Name
Welcome! So that we may provide you with the best possible care, please complete both sides of this dental & medical history form. All information is completely confidential and subject to all applicable laws.

Have you had the following disease or problems?

	Yes/No
Active Tuberculosis ?
Cough that produces blood ?

IF YOU ANSWER YES TO EITHER OF THE QUESTIONS ABOVE, PLEASE STOP AND RETURN THIS FORM TO THE RECEPTIONIST.
What is the reason for your visit today?
Last Dental Cleaning
Last Full-Mouth X-rays

Have you ever had...?

	Yes/No
Hot or cold?
Sweets?
Biting or Chewing?

Have you noticed or experienced...?

	Yes/No
Mouth odors or bad tastes?
Cold cores, blisters, or other mouth lesions?
Bleeding or painful gums?
Loose teeth or changes in your bite?
Does food tend to get caught between your teeth?

Do you...?

	Yes/No
Clench or grind your teeth while awake or asleep?
Bite your cheeks, lips or fingernails regularly?
Hold foreign objects with your teeth? (i.e., pens, pipe, nails)
Mouth breathe while awake or asleep?
Have tired jaws especially in the morning?
Snore or have any other sleeping disorders?
Smoke/chew tobacco or use other tobacco products?
Drink Coffee or tea?

	Yes/No
Do you feel nervous about dental treatment?
Orthodontic Treatment?
Do you wear a retainer?
Oral surgery?
Periodontal Treatment?
Your teeth or bite adjusted?

	Yes/No	How old is it?
A full/partial denture?
A mouth guard?

If you could change your teeth...?

	Yes/No
Whiter?
Straighter?
Remove space?
Replace metal filling w/tooth colored fillings?
Repair chipped teeth?
Replace missing teeth?
Replace old crowns that don't match?
Less gums showing?

Do you feel nervous about dental treatment?

YesNo
Are you satisfied with your teeth appearance?

YesNo
If so,what's your biggest concern?
How often do you brush your teeth?
How often do you floss?
Have you had any medical care within the past two years?

YesNo
Explain:
Physician Name

First NameLast Name
Phone Number

Area CodePhone Number
Describe

	Yes/No
5. Have you ever taken osteoporosis or bone loss prevention drugs such as Fosamax, Actonel, Boniva or other similar drugs?
6. Have you been a patient in the hospital during the past five years?
7. Have you ever had a serious injury to your head or mouth?
8. Have you ever been told to take a pre-medication prior to dental treatment?
9. Have you lost or gained more than 10 pounds in the past year?

	Yes/No
A.I.D.S./H.I.V Positive
Anemia
Arthritis/Rheumatism
Artificial Heart Valve/Pacemaker
Artificial Joints
Artificial Prosthesis
Asthma
Blood Disease Or Bleeding Disorder
Blood Transfusion
Bruise Easily
Cancer, Tumors, Growths
Celebral Palsy
Chemotherapy
Chest Pain
Chicken Pox
Chronic Cough
Cold Sores/Fever Blisters
Congenital Heart Disease
Contact Lenses
Cortisone Medicine
Diabetes
Diet(Special/Restricted)
Difficult Swallowing
Drug Addiction
Emphysema
Epilepsy or Seizures
Excessive Bleeding
Fainting or Dizzy Spells
Glaucoma
Hay Fever/Allergy/Hives
Head Injuries
Heart Attack, Disease, Surgery
Heart Failure
Heart Murmur
Hemophilia
Hepatitis A
Hepatitis B
Hepatitis C
Herpes
High/Low Blood Pressure
Kidney Infection or Disease
Liver Disease/Joundice
Mitral Valve Prolapse
Nervous Disorders
Neurological Disorders
Osteoporosis
Psychiatric/Psychological Care
Radiation Therapy
Rheumatic Fever
Scarlet Fever
Sinus Trouble
Stroke
Swollen Ankles
Thyroid Problems/Disease
Tonsillitis
Ulcer
Venereal Disease

PATIENT REGISTRATION

PATIENT REGISTRATION

DENTAL HISTORY