New Patient Registration Form

New Patient Registration Information

Please complete the form below
Name: *

First Name Middle Name Last Name
I prefer to be called:
Who may we thank for referring you?
Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Home Phone Number:

Area Code Phone Number
Cell Phone Number: *

Area Code Phone Number
E-mail: *
Birth Date *

Month Day Year
Sex: *

Male Female
Social Security: *
Marital Status:
Work Information
Employer:

First Name Last Name
Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Work Phone Number:

Area Code Phone Number
Occupation:
Guarantor/Insurance Policy Holder

Person Responsible for Account
Full Name: *

First Name Last Name
Birth Date: *

Month Day Year
Social Security Number: *
Employer:
Dental Insurance:

Insurance Co. Name

Insurance Co. Address:

City State / Province

Postal / Zip Code Country
Insurance Co Phone Number:

Area Code Phone Number
Subscriber ID Number:
Group/Policy Number:
Secondary Dental Insurance (If applicable):

Insurance Co. Name

Insurance Co. Address:

City State / Province

Postal / Zip Code Country
Insurance Co Phone Number:

Area Code Phone Number
Subscriber ID Number:
Group/Policy Number:
Dental Health Questionaire

We believe that each patient deserves to know what their level of dental health is, how they got there, and what treatment options are available to help them reach the level of health they deserve. This begins with the careful diagnosis and a personalized treatment plan. We will perform a comprehensive oral examination of your teeth, gums, jaw joints, bite, and soft tissues. We will also take appropriate x-rays, and when beneficial we may take additional diagnostic records such as photographs or casts of your teeth to further evaluate areas of concern. Once all your records have been completed, they will be carefully evaluated and we will review our findings with you and discuss treatment options. A personalized treatment plan will then be developed to help you achieve the goals we set together.
Please help us better understand your dental health needs and goals by answering all of the following questions:
When was your last dental cleaning/visit? (Approximately) *
I have a _________________ fear of visiting the dentist. *
My mouth/teeth are _________________ comfortable. *
I am ____________________ with the appearance of my teeth. *
I think my present state of dental health is: *
I am interested in a smile evaluation and personalized treatment plan to enhance my smile: *
My main concerns with my dental health are __________________:
Please check which statement best represents the level of dental health you wish to achieve: *
Medical History

Please complete the following information to the best of your knowledge.
Do you have or have you ever had any of the following? Please check all that apply. * This condition may require antibiotic pre-medication for certain dental procedures. *

Allergies/ Hay Fever Anemia Angina Arthritis Artificial Joints* Artificial Heart Valve* Asthma Breathing Problems Cancer Chemical Dependency Chemotherapy Diabetes Epilepsy Excessive Thirst Fainting / Diziness Fever Blister / Cold Sores Frequent Cough Glaucoma Heart Disorder (Congenital)* Heart Infection* Heart Murmur* Heart Pace Maker* Heart Surgery* Hepatitis High Blood Pressure HIV/AIDS Kidney Problems Liver Problems Mental Disorders Mitral Valve Prolapse Osteoporosis Radiation Treatment Respiratory Problems Rheumatic Fever Rheumatism Sickle Cell Disease Sinus Problems Stroke Surgical Shunt* Thyroid Problems Tuberculosis Ulcers Venereal Disease Yellow Jaundice NONE OF THE ABOVE Other
Do you have any health problems that were not listed above or that need further attention? *

Yes No
If Yes, please explain:
Are you now under the care of a physician? (More than routine care?) *

Yes No
If Yes, please explain:
Have you been admitted to a hospital or needed emergency care during the past 2 years? *

Yes No
If Yes, please explain:
Are you taking and medications or herbals? *

Yes No
If Yes, please list below:
Are you allergic to any medications or substances? If yes, please check all that applicable boxes: *

Yes No Aspirin Penicillin Codeine Iodine Metal Latex Other
Have you been diagnosed with COVID-19 or come in direct/close contact with someone that was confirmed positive? *

Yes No
WOMEN: Please check if applicable:

Pregnant Trying to get pregnant Nursing Birth Control Menopause Other
To the best of my knowledge, all the preceding answers are correct. IF I have any changes in my health status or if my medications change, I will inform the dentist and staff at the next appointment without fail. *
APPOINTMENTS

We value your time so you can expect us to see you at the appointed time and to keep your time spent in our office as short as possible. In return, when you make an appointment with us, please be on time as we have reserved our time just for you. Please make every effort not to change your scheduled appointment. If you must change an appointment, please provide us at least 24-hours advanced notification so that we may use our time to accommodate other patients. Broken and missed appointments create scheduling problems for other patients and our practice. If you are more than 10 minutes late for your appointment, you may be asked reschedule. We value your time, so we ask that you please value ours as well.
All missed appointments without 24-hour notice will incur a $50 no-show / late cancellation fee. Please initial acknowledgment of the fee. *
FINANCIAL POLICY

Unless another financial option is PRE-ARRANGED, payment is due the day of treatment, or on pre-op visits for sedation appointments. Should a patient have dental insurance with assignment to Dr. Cansler, the estimated patient portion will be the amount due. Insurance payments without assignment will be sent to the insured with payment due in full. Payment Options: For your convenience we accept cash, check, Visa, MasterCard, and Discover. We do not currently accept American Express, CareCredit, or LendingClub. For Patients with Dental Insurance: Dental insurance plans often pay less than the actual fee for service, therefore the patient or guarantor is the responsible party for all the dental services provided. Dental insurance in most cases is a benefit with limitations and should not be expected to take care of all costs. Your dental benefits and how they relate to your specific needs will be estimated and explained to you during the treatment discussion appointment. We will allow a maximum of 90-days for your insurance company to clear account balances. Any unpaid portions will be due in full by you after this period. Fees:Returned checks are subject to a $30 account fee or 5% of check amount over $600.
AUTHORIZATION AND CONSENT

General Consent to Treatment: I agree and consent to a dental examination by Dr. Cansler. I understand that additional diagnostic procedures and dental treatment may be recommended and will be discussed with me prior to being done. Also, I acknowledge that there are no guarantees, expressed or implied, as to the results of any procedures or dental treatment performed. Release of Information: I authorize Dr. Cansler to release an information regarding my dental/medical history, diagnosis or treatment to third party payors and/or other health professionals. Assignment of Insurance Benefits: I authorize and request my insurance company to pay my benefits directly to Dr. Cansler. Photography Release: I authorize Dr. Cansler to take photographs of me to help me better understand my current dental condition and possible treatment options. I understand and will comply with Appointment Policy. I understand and comply with the office Financial Policy. I understand and agree to the General Consent for Treatment.
Signature of Patient/Parent/Guardian *
NOTICE OF PRIVACY FOR PROTECTED HEALTH INFORMATION

I hereby acknowledge that I have reviewed Cansler Dental’s Notice of Privacy Practices. I understand that I may ask any questions I might have regarding this notice.
Date:

Month Day Year
Hour Minutes AM/PM Option
Signature of Patient/Parent/Guardian *
Please verify that you are human *
Should be Empty:

New Patient Registration Information

Work Information

Guarantor/Insurance Policy Holder

Dental Health Questionaire

Medical History

APPOINTMENTS

FINANCIAL POLICY

AUTHORIZATION AND CONSENT

NOTICE OF PRIVACY FOR PROTECTED HEALTH INFORMATION