What's New? *CURRENT PATIENTS ONLY!*

What's New? *CURRENT PATIENTS ONLY!*

IF YOU ARE A NEW PATIENT TO LANGAN DENTAL, PLEASE GO TO https://form.jotform.com/232193805418154 AND FILL OUT NEW PATIENT PAPERWORK. PLEASE FILL OUT THE BELOW UPDATE FORMS. THESE NEED TO BE FILLED OUT EVERY 2 YEARS. THANK YOU FOR YOUR COOPERATION!
Today's Date:*

MonthDayYear
Date
Patient Name:*

First NameLast Name
Patient Date of Birth:*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Patient Social Security Number:
Cell Number:
Please enter a valid phone number.
Home Number:
Please enter a valid phone number.
Work Number:
Please enter a valid phone number.
E mail Address:
example@example.com
INSURANCE INFORMATION:
Has any of your insurance information changed? If no please scroll down to the Medical Update section.*

NOYES
New Insurance Company Name:
New Policy Number:
New Group Number:
Please upload a picture of FRONT of your NEW insurance card:

Cancelof
Please upload a picture of BACK of your NEW insurance card:

Cancelof
I hereby authorize assignment of my insurance rights and benefits directly to the provider for services rendered. I fully understand I am solely responsible for any balance not paid by my insurance company.
Signature*

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MEDICAL INFORMATION:
What medications are you taking? if none please type none. *
You can upload a picture of your medication list here:

Cancelof
Please list any allergies. If none please type none.*
Please list any new diseases, medical conditions or procedures with procedures dates: If none please type none. *
In the even of an emergency, whom should we contact? *

First NameLast Name
Relation:*
Phone Number*
Please enter a valid phone number.
Which office of ours are you a patient at? *
I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any further changes to the information I have provided.
Patient Signature: *

Clear
Date*

MonthDayYear
Date
HEALTH HISTORY REVIEW
Medical(Primary Care Physician) Doctor Name & Phone number *
Estimated date of last visit

MonthDayYear
Date
Have you ever used a bisphosphonate Medication? Common brands are Fosamax, Actonel, Atelvis, Didronel, Bonevia*

YesNo
Have you ever taken any of the group of drugs collectively referred to as "fen-pen": There included combinations of lonimin, Apipex, Fastin (Brand names of phentermine), Pondimin,(fenfluramine) and Redux (dexfenfluramine).*

YESNO
Parent/Guardian Signature

Clear
IF YOU ARE PREGNANT. YOU MUST HAVE YOUR OBGYN SEND US A CLEARANCE FORM TO IN ORDER TO SEE YOU.

570-319-9754 FAX OR EMAIL IT TO LANGANDENTALGROUP@GMAIL.COM
ARE YOU PREGNANT?*

YESNO
IF YES, WHAT IS YOUR DUE DATE?

MonthDayYear
Date
DO YOU TAKE A BLOOD THINNER?*

YESNO
ARE YOU TAKING BIRTH CONTROL PILLS*

YESNO
DO YOU WEAR CONTACT LENSES?*

YESNO
PLEASE CHECK ANY OF THE FOLLOWING THAT APPLY TO YOU

AIDS/HIVANEMIAARTHRITIS, RHEUMATISMARTFICIAL HEART VALVESARTIFICAL JOINTSASTHMABACK PROBLEMSBLEEDING ABNORMALLY WITH EXTRACTIONS OR SURGERYBLOOD DISEASECANCERCHEMICAL DEPENDENCYCHEMOTHERAPYCIRCULATORY PROBLEMSCONGENTIAL HEART LESIONSCORTISONE TREATMENTSCOUGH, PERSISTANT OR BLODDYDIABETESEMPHYSEMAEPILEPSYFAINTING OR DIZZINESSGLAUCOMAHEADACHESHEART MURMURHEART PROBLEMSHERPESHIGH BLOOD PRESSUREJAUNDICEJAW PAINKIDNEY DISEASELIVER DISEASELOW BLOOD PRESSUREMITRAL VALVE PROLAPSENERVOUS PROBLEMSPACEMAKERPSYCHIATRIC CARERADIATION TREATMENTRESPIRATORY DISEASERHEUMATIC FEVERSCARLET FEVERSHORTNESS OF BREATHSINUS TROUBLESKIN RASHSPECIAL DIETSTROKESWOLLEN FEAT OR ANKLESSWOLLEN NECK GLANDSTHYROID PROBLEMSTONSILLITISTUBERCULOSISTUMOR OR GROWTH ON HEAD OR NECKULCERVENEREAL DISEASEWEIGHTLOSS, UNEXPLAINED
Do you have Hepatitis?
IF YOU HAVE ARTFICAL JOINTS/HEART VALVE REPLACEMENT - EX: HIP, SHOULDER, KNEE ETC.. DO YOU NEED TO TAKE AN ANTIOBIOTIC PRE MEDICATION? IF YOU DON'T KNOW. YOU MUST CALL YOUR DOCTOR AND HAVE THEM SENT MEDICAL CLEARANCE WITH THE ANSWER 570-319-9754 FAX question*

YES I PREMEDNO I DON'TI DON'T KNOWI DON'T HAVE ANY ARTFICAL JOINTS/HEART VALVE REPLACEMENT
Allergies

AsprinBarbituatesCodeineIodineLatexLocal AnesteheticPenicillinSulfaOther
LANGAN DENTAL RELEASE/CONSENT FORM
PATIENTS NAME *

First NameLast Name
BEST PHONE NUMBER TO CALL / TEXT TO CONFIRM APPOINTMENTS

–By providing your cell number you agree to receive SMS text messages for marketing purposes–
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Email
example@example.com
PATIENTS BIRTHDAY *

MonthDayYear
Date
RADIOGRAPHS & CLINICAL RECORDS RELEASE

BY SIGNING THIS YOU GIVE PERMISSION FOR LANGAN DENTAL TO SEND YOUR RADIOGRAPHS & CLINICAL RECORDS TO OTHER DOCTORS/SPECIALISTS YOU MAY BE REFERRED TO BY LANGAN DENTAL
Signature*

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Date*

MonthDayYear
Date
ASSIGNMENT OF BENEFITS FOR INSURANCE REIMBURSEMENT

BY SIGNING THIS YOU’RE AGREEING FOR THE INSURANCE PAYMENT TO BE RELEASED TO LANGAN DENTAL
Signature*

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Today's Date *

MonthDayYear
Date
HIPPA Contact Release Form

In order to help us stay within the guidelines of HIPAA, please list below any person/persons that you authorize us to discuss information regarding your Protected Health Information, including billing information. If you do not wish to list anyone, please put N/A.

(You do not need to list any of your other doctors)
NAME:
RELATIONSHIP:
Phone Number
Please enter a valid phone number.
NAME:
RELATIONSHIP:
Phone Number
Please enter a valid phone number.
INFORMED CONSENT FOR THE TREATMENT OF CONDITIONS AND EXPLANATIONS HAVE BEEN REVIEWED

Exams, Fillings, Root Planings, Crowns, Implant Crowns, Extractions, Surgical Extractions, Root Canal Therapy, Radiographs, Partial Dentures, Complete Dentures, Anesthetics, Photos.

The most common risks can include, but are not limited to:

Bleeding, swelling, bruising, discomfort, stiff jaws, infections, aspiration, paresthesia, nerve disturbance or damage either temporary or permanent, adverse drug response, allergic reaction, and cardiac arrest.
Patient / Guardian Signature*

Clear
TODAY'S DATE *

MonthDayYear
Date
CANCELLATION, INSURANCE & APPOITMENT POLICY

OUR OFFICE STAFF WILL DO THE BEST THEY CAN TO ASSIST YOU WITH YOUR INSURANCE BUT CANNOT BE RESPONSIBLE FOR YOUR POLICY’S COVERAGE. DENTAL INSURANCE IS DESIGNED TO AID IN YOUR DENTAL CARE AND IS IT NOT INTENDED TO BE A PAY ALL.

THERE ARE NUMEROUS INSURANCE COMPANIES, ALL WITH DIFFERENT TYPES OF PLANS. WE CANNOT FULLY GUARANTEE YOUR PLAN BENEFITS. WHETHER YOUR PLAN IS SELF-FUNDED, GOVEREMENT FUNDED OR YOU HAVE IT THROUGH YOUR EMPLOYER - IT’S ALWAYS BEST TO DIRECT ALL YOUR QUESTIONS TO YOUR INSURANCE ADVISOR.

BY SIGNING BELOW YOU’RE AGREEING TO PAY ANY BALANCES AND COPAYS AT THE TIME OF YOUR SCHEDULED VISIT. YOU ALSO AGREE TO PAY ALL COLLECTION FEES & COURT COSTS IF LANGAN DENTAL MUST SEND THE PATIENT TO COLLECTIONS.

OUR APPOINTMENT CANCELLATION POLICY IS AS FOLLOWS…

*ANY PATIENT WITH A SCHEDULED APPOINTMENT THAT CANCELS WITH LESS THAN OUR REQUIRED NOTICE OF 24 HOURS WILL BE ASSESSED A “CANCELLATION FEE” OF $75.00.

*ANY GROUP APPOINTMENT (FAMILY APPOINTMENTS ETC..) THAT FAIL TO CANCEL WITHIN THE REQUIRED 24 HOUR NOTICE WILL NOT BE RE BOOKED AS A GROUP APPOINTMENT AGAIN.

*IF YOU FAIL TO CANCEL YOUR APPOINTMENT WITHIN THE REQUIRED 24 HOURS NOTICE - AFTER YOUR 3RD MISS, YOU WILL BE DISMISSED FROM THE PRACTICE.

*APPOINTMENTS MUST BE CONFIRMED. IF WE HAVE YOUR CELL PHONE NUMBER - OUR SYSTEM WILL TEXT YOU TO CONFIRM. YOU WILL NEED TO REPLY “YES” IN ORDER TO CONFIRM.. IF WE DO NOT WE WILL CALL YOU. IF YOU DO NOT CONFIRM YOUR APPOINTMENT AT LEAST 24 HOURS BEFORE YOUR SCHEDULED VISIT, YOUR APPOINTMENT MAY BE ASSIGNED TO ANOTHER PATIENT..

BY SIGNING BELOW, YOU AGREE TO ALL OF THE TERMS ABOVE.
Today's Date*

MonthDayYear
Date
Patients Name *

First NameLast Name
Patient DOB *

MonthDayYear
Date
Patient Signature

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Should be Empty:

What's New? *CURRENT PATIENTS ONLY!*

INSURANCE INFORMATION:

MEDICAL INFORMATION:

HEALTH HISTORY REVIEW

What's New? CURRENT PATIENTS ONLY!