New Patient Registration Form

Is the patient an adult?18 years old or older

YESNO

Patient Name* This field is required.

First Name

Last Name

Preferred Name(If different than first name)

Gender Identity* This field is required.

Date of Birth* This field is required.

Date

Social Security Number

Mailing Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Home Phone Number

Area Code

Phone Number

Mobile Phone Number

Area Code

Phone Number

Billing Statement Delivery Method

Mail

Employer

Employer Name

Occupation

Family members who are current patients at Carbondale Family Dental

Parent/Guardian Name

First Name

Last Name

Parent/Guardian Date of Birth

Date

Relationship to Patient

Mother

Father

Legal Guardian

Other

Is the Parent/Guardian a current patient at CFD?

Yes

Is the Billing Address the same as the patient's?

Yes

Parent/Guardian Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Parent/Guardian Phone Number

Area Code

Phone Number

Parent/Guardian Email

example@example.com

How did you hear about us? We love to thank our patients for referrals!

Previous DentistPlease fill out a records release form if you'd like us to request x-rays and records from a previous dentist.

Name

Date of Last Visit

Emergency Contact* This field is required.No personal information will be disclosed.

Name

Phone Number

Does the patient have Dental Insurance?* This field is required.Please note that we are an out-of-network provider for all insurance companies, but accept all insurance plans (except Medicare & Medicaid) and will bill your plan on your behalf. More details are included in our Financial Policy.

YESNO

Please upload front and back of dental insurance card Or you can provide card to our office staff.

Drag and drop files here

Select files to upload

Physician

Physician's Name

Phone Number

Patient's current physical health is* This field is required.

Good

Fair

Poor

Is the patient currently under the care of a physician for a specific condition?* This field is required.

Yes

If yes, please explain

Has the patient had any surgeries in the last five years?* This field is required.

Yes

If yes, please list type and date

Has the patient ever had a joint replacement?* This field is required.

Yes

If yes, please list type and date

Is the patient currently taking any medications?* This field is required.Prescription and over-the-counter

Yes

If yes, please list it herePlease list all medications (DRUG NAME, DOSE, FREQUENCY, ROUTE) that you are currently prescribed, if more than one, separate them with a comma.

Has the patient ever taken Fosamax, Phen-fen, or any biphosphonate?* This field is required.

Yes

Is the patient allergic to any of the following?

Aspirin

Chlorhexidine

Codeine

Dental Anesthetics

Erythromycin

Iodine

Jewelry

Latex

Metals

Penicillin

Tetracycline

Other

Is the patient using a prescribed method of birth control?

Yes

Is there a possibility the patient could be pregnant?

Yes

Is the patient currently breast feeding?

Yes

Does the patient have any of the following medical conditions?

Abnormal bleeding

Alcohol/drug abuse

Anemia

Arthritis

Artificial bones/joints/valves

Asthma

Autism

Blood transfusion

Cancer/chemotherapy

Colitis

Congenital heart defect

Diabetes

Difficulty breathing

Emphysema

Epilepsy

Fainting spells

Frequent headaches

Glaucoma

Hay fever

Heart attack (family history)

Heart murmur

Heart surgery

Hemophilia

Hepatitis

Herpes/fever blisters

High blood pressure

HIV+/AIDS

Kidney problems

Liver disease

Low blood pressure

Mitral valve prolapse

Pacemaker

Psychiatric problems

Radiation treatment

Rheumatic/scarlet fever

Seizures

Shingles

Sickle cell disease/traits

Sinus problems

Sleep Apnea/CPAP

Stroke (family history)

Thyroid problems

Tuberculosis

Ulcers

Venereal disease

Other

If other, please explain

The patient's current dental health is* This field is required.

Good

Fair

Poor

Is the patient currently in pain?* This field is required.

Yes

Has the patient ever had difficulty with previous dental work?* This field is required.

Yes

Do the patient's gums bleed?* This field is required.

Often

Occasionally

Rarely/Never

To your knowledge, does the patient require antibiotics before dental treatment?* This field is required.

Yes

How many times a day does the patient brush his/her/their teeth?* This field is required.

How many times a week does the patient floss his/her/their teeth?* This field is required.

Does the patient smoke or use tobacco or marijuana?* This field is required.

Yes

Signature* This field is required.The information I have provided on this form is correct to the best of my knowledge.

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FINANCIAL POLICY

Thank you for choosing us as your dental care provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered a part of your treatment. The following is a statement of our Financial Policy which we require you to read and sign prior to any treatment.

Payment is due at the time of service.
If you have insurance, we expect you to pay your estimated portion at the time of service.
We accept cash, checks or credit cards.
We offer an extended payment plan with prior credit approval.

Insurance

We are an out-of-network provider for all insurance companies and we will file your insurance claims for you as a courtesy. Your insurance policy is a contract between you and your insurance company and it is your responsibility to ensure we have correct and current insurance information, and that you understand the benefits available to you. Please be aware that some of the services we provide may not be covered under your insurance policy. Once your insurance company has paid your benefits, you are responsible for any remaining balance.

Usual and Customary Rates

Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary to our area. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates.

Late Fees and Collection Costs

If a payment is not paid within the terms of an agreed upon payment plan, Carbondale Family Dental may asses a delinquency charge in an amount not exceeding the greater of 10% of the unpaid amount of the installment not to exceed $15.00 provided that such charge may be collected at the time it accrues or any time thereafter but only one such charge shall be made for each installment in default regardless of the length of the period it remains unpaid.

In the event of any default, Carbondale Family Dental may declare the entire unpaid balance to be immediately due and payable. If Carbondale Family Dental then assigns this agreement to a collection agency for recovery, the patient will also be responsible for up to 30% of the unpaid principle balance as the reasonable cost of collection.

Minor Patients

The adult accompanying a minor is responsible for payment.

Missed Appointments

We ask that you please call at least 24 hours in advance if you cannot keep your appointment. If you miss an appointment, we ask that you provide a credit card to secure your future appointment. A $65 fee will be assessed for multiple missed appointments.

Thank you for understanding our Financial Policy. Please let us know if you have questions regarding this policy.

Financial Policy* This field is required.I have read, understand, and agree to Carbondale Family Dental's Financial Policy.

Clear

Health Privacy Notice* This field is required.I acknowledge that I have read Carbondale Family Dental's Notice of Privacy Policies: http://www.carbondalefamilydental.com/privacy_notice.pdf.

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New Patient Registration Form