Patient Registration Form -Insurance

Name

First NameLast Name

Preferred name

Date of Birth*

Date

Marital Status

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Social Security #*

Email*

example@example.com

Phone (Home)

Area CodePhone Number

Work Number

Area CodePhone Number

Cell Phone*

Area CodePhone Number

Reason for visit*

Date of Last Dental Visit*

List all current medications:*

Please list all allergies:*

Have you ever had any complications following dental treatment?

Have you been admitted to a hospital or needed emergency care during the past two years?*

Name of Physician:

Physician Phone Number

Area CodePhone Number

Pharmacy

Please include phone number OR location

Do you have any health problem that need further clarification?

To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail.

Signature*

Whom may we thank for referring you to our practice?*

Name of the person or office referring you to our practice

Employer Name:

Occupation:

Do you have dental insurance?*

Name of subscriber

First NameLast Name

Is the subscriber a patient?

Subscriber birthdate

ID#

Group#

Insurance plan name and phone number*

Patient's relationship to subscriber

SelfSpouseChildOther

Name of subscriber

First NameLast Name

Is the subscriber a patient?

Subscriber's birthdate:

ID#

Group #

Insurance plan name and phone number

Patient's relationship to subscriber

SelfSpouseChildOther

As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment.

All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed.

Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patients insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.

A service charge of 1½% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied.

I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination.

In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, or within five (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder.

I have received a NOTICE of PRVACY PRACTICES from the office of Dr. Michael C. Byars D.D.S.

I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form.

I have read the above conditions of treatment and payment and agree to their content.

Signature*

Do you dislike the color of your teeth? *

Do you have spaces between your teeth that bother you?*

Do you have chips or uneven edges in your teeth?*

Do you feel your teeth are too long or too short?*

Do you have dark fillings that show when you smile?*

Do your gums show too much when you smile?*

Are your teeth crooked or crowded?*

Do you have existing crowns or dental work that you consider "ugly"?*

Are you self conscious of your teeth and or smile? *

Has anyone (friend, family member, ect.) ever suggested that you do something about your smile?*

Do you avoid smiling when you have a photo taken?*

Would you like to improve your existing smile?*

Do you wish you had a "new smile"?*

Patient Registration Form

Health Information

Have you ever had any of the following? Please check those that apply:

Referral Information

Employment Information

Dental Insurance Information

Secondary Insurance

Consent for Services

Smile Evaluation