Lenderman Dental Patient Registration

  • Patient Registration

  • Patient Is:

  • Please fill out the Responsible Parties Information Below

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  • Please Choose One:
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  • Sex:
  • Marital Status:
  • I would like to receive correspondences via email.
  • Employment Status (choose all that apply)
  • Do you have a preferred dentist?
  •  -
  • How did you hear about us?

  • Insurance Information

  • Does the patient have Dental Insurance?

  • Primary Insurance Information

  • Relationship to the Insured:

  • Does the patient have a secondary insurance?

  • Secondary Insurance Information

  • Relationship to the Insured:

  • Medical History

  • Are you under a physician's care now?
  • Have you ever been hospitalized or had a major operation?
  • Have you ever had a serious head or neck injury?
  • Are you taking any medications, pills, or drugs?
  • Do you take, or have you taken, Phen-Fen or Redux?
  • Have you ever taken Fosamax, Boniva, Actonel, or any other medications containing bisphosphonates?
  • Are you on a special diet?
  • Do you use tobacco?
  • Do you use any controlled substance?
  • Women: Are you...
  • Are you allergic to any of the following?

  • Do you have, or have you had, any of the following

  • Have you ever had any serious illness not listed above?

  • To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status. 

  • Date
     - -

  • Dental History

  • How would you rate the condition of your mouth?
  • Date of most recent treatment (other than a cleaning)
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  • Date of most recent dental x-rays
     - -
  • I routinely see my dentist every:

  • Personal History

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  • Have you ever had an unfavorable dental experience?
  • Have you ever had complication from past dental treatment?
  • Have you ever had trouble getting numb or had any reactions to local anesthetic?
  • Have you ever had braces, orthodontic treatment or had your bite adjusted, and at what age?
  • Have you had any teeth removed or missing teeth that never developed or lost teeth due to injury of facial trauma?

  • Gum and Bone

  • Do your gums bleed or are they painful when brushing or flossing?
  • Have you ever been treated for gum disease or been told you have lost bone around your teeth?
  • have you ever notices unpleasant taste or odor in your mouth?
  • Is there anyone with a history of periodontal disease in your family?
  • Have you ever experienced gum recession?
  • Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?
  • Have you experienced a burning or painful sensation in your mouth not related to your teeth?

  • Tooth Structure

  • Have you had any cavities within the past 3 years?
  • Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?
  • Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?
  • Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth?
  • Do you have grooves or notches on your teeth near the gum line?
  • Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?
  • Do you frequently get food caught between any teeth?

  • Bite and Jaw Joint

  • Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)
  • Do you feel like your lower jaw is being pushed back when you bite your back teeth together?
  • Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry food?
  • In the past 5 years, have your teeth changed (become shorter, thinner, or worn) or has your bite changed?
  • Are your teeth becoming more crooked, crowded, or overlapped?
  • Do you have trouble finding your bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together?
  • Do you place your tongue between your teeth or close your teeth against your tongue?
  • Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?
  • Do you clench or grind your teeth together in the daytime and make them sore?
  • Do you have any problems with sleep (i.e. sleep restlessness or teeth grinding), wake up with a headache or an awareness or your teeth?
  • Do you wear or have you ever worn a bite appliance?

  • Smile Characteristics

  • Is there anything about the appearance of your teeth that you would like to change? (shape color size?
  • Have you ever whitened your teeth?
  • Have you felt uncomfortable or self conscious about the appearance of your teeth?
  • Have you been disappointed with the appearance of previous dental work?

  • Lenderman and Meek Dental

    Financial Policy and Dental Insurance

  • Our office is committed to providing you with the best possible care. If you have dental insurance, we will help you to receive your maximum allowable benefits. To do this, we need your assistance and your understanding of our financial policy.

    Payment for services is due at the time services are rendered. We accept cash and all major credit cards. We also offer no-interest payment plans for 6 or twelve months through CareCredit and CHERRY. If you have insurance, we will be happy to process your claim for you. Please be prepared to pay your estimated portion on the date of service. It is impossible for us to know all our patients’ insurance coverage and additional payments may be necessary once your claim has been processed.

    Late/NO- Show Policy: To ensure we can accommodate all our patients; any cancellation or rescheduling requests must be submitted 24 hours in advance. A fee of $40.00 will be imposed for the second consecutive no-show. The patient will be dismissed from the practice after three consecutive no-shows. If you are 15 minutes late on arrival, your appointment will be cancelled, and you will be asked to reschedule.

    Returned checks will be subject to additional collection of $25.00

    Our office will gladly discuss your proposed treatment and answer any questions relating to your insurance. You must realize however that your insurance is a contract between you, your employer and the insurance company. We are NOT a party to that contract. Dental insurance is not meant to be a pay-all: It’s only meant to be an aid. Many routine dental services are not covered by dental insurance at all. If you should have any questions regarding your coverage, YOU should contact your company.

    We must emphasize that as dental care providers, our relationship is with you, NOT your insurance company. While the filing of all insurance claims is a courtesy we extend to our patients, ALL charges are YOUR responsibility.

    In a single parent family or divorced situations where children are involved, the parent bringing the child/children to the office for treatment will be fully responsible for payment.

    If you have any questions about the above information or are uncertain regarding insurance information, please do not hesitate to ask us. We are here to help you.

    ASSIGNMENT & RELEASE: I have read all the information on this sheet. I hereby authorize my insurance benefits to be paid directly to Lenderman and Meek Dental. I understand and agree that (regardless of my insurance), I am responsible for the balance on my account for any professional services rendered. In the event that the services of an attorney or collection agency is required to collect any portion of payment due for my dental services rendered, additional fees may be incurred. I understand and agree that I will be responsible for payment of ALL fees related to collection of my account including attorney fees, collection agency fees and court costs.

  • Lenderman and Meek Dental HIPAA Consent Form

  • THIS NOTICE DESCRIBES TO WHOM MEDICAL INFORMATION ABOUT YOU MAY BE DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
    _______________________________________________________________
    The Health Insurance Portability and Accountability Act of 1996 (HIPAA) provides privacy protections to your medical records. Our benefits office (or other third party designated by our office) may sometimes need to disclose medical information or payment information protected by HIPAA in relation to our group health plans to your family members or close friends involved in your health care. For example, your spouse may need to contact us if you are in the hospital to determine whether a particular procedure is covered under our group health plan or may need assistance filing a claim for medical services. Under HIPAA, unless you specifically object we are allowed to use our professional judgment in deciding whether to discuss you medical and payment information with you family members or close friends. However, we would like to provide you with the opportunity to tell us with whom we may discuss your medical or payment information under our group health plans.

  • COMPLAINTS


    If you think that we have not properly respected the privacy of your health
    information, you are free to complain to us or the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to the office contact person at the address, fax or E mail shown at the beginning of this Notice. If you prefer, you can discuss your complaint in person or by phone.


    FOR MORE INFORMATION

    If you want more information about our privacy practices, call or visit the office
    contact person at the address or phone number shown at the beginning of this Notice.

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