New Patient Registration Form

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1 New Patient Registration Form Welcome to Bayside Dental Care! We look forward to giving you the best dental experience possible. Please complete both sides of this form. Let us know if you need any assistance with it. Patient Name Date First Middle Last Social Security # Birth Date Best way to contact you? Home Address Home Phone Street City State Zip Mobile Work Phone Marital Status: Single Married Divorced Widowed Spouse's Name and Phone How did you learn about our practice? Recommendation from a friend or family member. If so, who may we thank? Recommendation from another healthcare provider. If so, who may we thank? Internet search Yelp other Have you visited our website (baysidedentaldds.com)? Yes No Do you have any friends or family members who may need dental care? Insurance Section Do you have dental insurance? Yes No if yes, please complete the following: Name of Insured Person Relationship to Patient Birth Date Social Security # Name of Employer Work Phone Address of Employer Primary Insurance Company Group # Union/Local # Do you have additional dental insurance? Yes No if yes, please complete the following: Name of Insured Person Relationship to Patient Birth Date Social Security # Name of Employer Work Phone Address of Employer Secondary Insurance Company Group # Union/Local # Emergency Contact Person Relationship Home Phone Mobile Phone Work Phone Person responsible for account (if not you) Relationship Birth Date Home Phone Mobile Phone Work Phone Is this person a patient in our office? Yes No

2 Dental and Medical Section Current dental problems: Last dentist s name and city: When was your last dental visit? What was done then? Dental Questions 1. Have you ever had a bad dentist experience?... Yes No 2. Do you feel nervous about having dental treatment?... Yes No 3. Is there anything you would like to speak about with the doctor about in private?... Yes No 4. Do you have any tooth or gum pain right now?... Yes No 5. Do your gums bleed easily?... Yes No 6. Are your teeth sensitive to hot or cold?... Yes No 7. Are your teeth sensitive to certain foods?... Yes No 8. Any loose teeth?... Yes No 9. Any sores or lumps in your mouth?... Yes No 10. Do you clench or grind your teeth?... Yes No 11. Does your jaw ever hurt?... Yes No 12. Have you ever had braces?... Yes No 13. Might you have bad breath?... Yes No 14. Would you like whiter teeth?... Yes No 15. Do you want to improve your smile?... Yes No Medical Questions 1. Are you presently under the care of an M.D.?... Yes No Physician's Name/Phone: 2. Have you ever had high blood pressure?... Yes No 3. Has a physician ever said you have heart trouble?... Yes No 4. Do you have Mitral Valve Prolapse?... Yes No 5. Have you ever had excessive bleeding from a cut or tooth extraction?... Yes No 6. Have you ever had an anesthetic (either local or general)?... Yes No 8. Are you allergic to penicillin, Novocaine or any other medication?... Yes No If yes, please explain: 9. Are you allergic to anything other than medicine, such as latex rubber or metals?... Yes No If yes, please explain: 10. Are you pregnant?... Yes No 11. Do you have a pacemaker?... Yes No Do you have or have you ever had: 1. Heart murmur... Yes No 2. Rheumatic fever?... Yes No 3. Rheumatic heart disease?... Yes No 4. Heart attack?... Yes No 5. Stroke?... Yes No 6. Epilepsy or convulsions?... Yes No 7. Fainting or dizziness?... Yes No 8. Anemia or leukemia?... Yes No 9. Low platelets... Yes No 10. Stomach ulcer?... Yes No 11. Cancer?... Yes No 12. Radiation therapy?... Yes No 13. Asthma or hay fever?... Yes No 14. Eczema or hives?... Yes No 15. Arthritis?... Yes No 16. Glaucoma?... Yes No 17. Tuberculosis?... Yes No 18. HIV / AIDS?... Yes No 19. Syphilis?... Yes No 20. Diabetes?... Yes No 21. Kidney trouble?... Yes No 22. Prostate trouble?... Yes No 23. Liver trouble or jaundice?... Yes No 24. Hepatitis?... Yes No 25. Thyroid trouble or goiter?... Yes No 26. Psychiatric treatment?... Yes No Are you now taking: 1. High blood pressure drugs?... Yes No 2. Drugs for sleep?... Yes No 3. Cortisone, steroids, ACTH?... Yes No 4. Anticoagulants or blood thinner?... Yes No 5. Tranquilizers or sedatives?... Yes No 6. Antibiotics?... Yes No 7. Insulin?... Yes No 8. Any other drugs? Have you ever been under the care of a physician for any major illness or injury other than those noted above? If so, please explain below: 1. To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication. 2. I agree to be responsible for all costs and fees that my insurance carrier does not pay. 3. I consent to receiving x-rays and an oral examination. 4. I have received a copy of the "Notice of Privacy Practices." Patient or Guardian Signature Date Updates: Has anything changed since you completed this form? Signature Date Changes Yes No Yes No

3 3 Health Questionnaire and Acknowledgement with Consent to Proceed: I certify that my answers to the health questions are accurate and correct to the best of my knowledge. Since a change of medical condition or medications can affect dental treatment, I understand the importance of, and agree to notify the dentist of any changes at any subsequent appointment. I authorize Bayside Dental Care and/or such associates of assistants as they may designate, to perform those procedures as may be deemed necessary or advisable to maintain my dental health or the dental health of any minor or other individual for which I have responsibility, including arrangement and/or administration of any sedative (including nitrous oxide), analgesic, other pharmaceutical agent(s), including those related to restorative, palliative, therapeutic or surgical treatments. I understand that the administration of local anesthetic may cause an untoward reaction or side effects, which may include but are not limited to bruising, hematoma, cardiac stimulation, temporary or permanent numbness, and muscle soreness. I do voluntarily assume any and all possible risks, including the risk of substantial and serious harm, if any which may be associated with general preventive and operative treatment procedures in hopes of obtaining the potential desired results, which may or may not be achieved, for my benefit or for the benefit of my minor child or ward. I acknowledge that the nature and purpose of the foregoing procedure have been explained to me as necessary and I have been given the opportunity to ask questions. The undersigned hereby authorizes Doctor to take x-rays, study models, photographs, or any other diagnostic aids deemed appropriate by Doctor to make a thorough diagnostic of patient s dental needs. Signature of Individual or Parent/Guardian Date

4 4 Financial Agreement Policy Thank you for choosing us for optimal oral health care. We have found that our patients appreciate knowing exactly what to expect from us both from a philosophy aspect and a financial aspect. Therefore, we prefer to inform our patients of these before we begin any treatment. Our Vision: person. Providing complete, life-long dentistry with excellence and integrity while keeping a focus on the whole Financial Arrangements: We offer the following methods of payment for services provided. This will allow us to focus on our specialty, providing you with superior customer service and optimal dentistry in a comfortable environment using up-to-date materials while keeping our fees as affordable as possible. 1. Cash, Check, Debit Card, MasterCard, Visa, Discover & American Express Accepted Payment in full is due when services are performed unless financial arrangements have been made prior to treatment. 2. 5% Courtesy A 5% courtesy will be given when services are paid in full prior to the appointment date. 3. Dental Financing Plan We have made arrangements with a company that will finance your dental work with approved credit. This will allow you to complete your dental work without delay, make no initial payment and have low monthly payments with interest free options. Application forms are available at the reception desk. Dental Insurance Most insurance companies will not cover 100% of all dental expenses. Your portion, not covered by insurance, is due at the time treatment is performed. Please understand that dental insurance is a contract between the patient and the insurance carrier, and not between the insurance carrier and the dentist. The patient is still the responsible party regarding dental fees. We will be glad to process your insurance forms at no charge. Dental Insurance Estimates Based on the information we have from your insurance company, we will ESTIMATE your portion of dental fees and payment will be due at the time of service. If there is a balance due after your insurance company pays their portion, you will be billed for any amount unpaid. You are responsible for any charges exceeding your benefits. Our office will assist in making collections from the insurance company by filing the necessary forms. However, our office cannot render services based on the assumption that charges will be paid by the insurance company. Returned Checks A $40.00 charge will be applied to all returned checks. I HAVE READ AND ACCEPT THE TERMS AND CONDITIONS OF THE FINANCIAL AGREEMENT AND I AUTHORIZE MY INSURANCE COMPANY TO PAY MY DENTAL BENEFITS DIRECTLY TO THE PRACTICE. Signature Date

5 5 Appointments and Cancellations When we make your appointment, we are reserving a room for your particular needs. We ask that if you must change an appointment, please give us at least 24 hour notice. This courtesy makes it possible to give your reserved room to another patient who would like it. There is a charge for not showing up for scheduled appointments. Repeated cancellations or missed appointments will result in loss of future appointment privileges. We feel that our patient's time is valuable. When your appointment is made, a room is reserved, your records are prepared, and special instruments are readied for your visit. Except for emergency treatment for another patient, you can expect us to be prompt. We, of course, would appreciate the same courtesy from you. I acknowledge I have read and understood the above statement Print Name Signature Date

6 6 Handle Me with Care I gag easily. I feel out of control when I am lying down in the dental chair. I have not been to the dentist for a long time and I feel uncomfortable about what will say or think about my teeth and my dental hygiene. I know I have bad habits that are causing harm to my dental health. I am afraid I might not be able to break them. Pain relief is a top priority to me. I don't like shots, or I've had a bad reaction to shots. Please tell me what I need to know about my mouth so I can make an informed decision. My teeth are very sensitive. I don't like the sound of that tool that makes the picking and scraping noise. I don't like cotton in my mouth. I hate the noise of the drill. I don't like the dental office smells. Please respect my time. I don't want to be left sitting in the reception area. I want to know the cost up front. No money surprises, please. I have difficulty listening and remembering what I hear while sitting in the dental chair. I have health problems and questions that we need to discuss. I don't like being left alone in the treatment area. I have problems with my back. I don't like the chair tipped back too far. I do not like to see dental instruments. I need to talk to you first, without sitting in the dental chair. Other concerns I would like to talk about (Please specify):

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