Registration 2022

Patient name & information
Name*

First NameLast Name
Preferred name
If applicable
Upload a photo for your patient profile
...or take a selfie photo
Social security number (SSN)*
This is so we can verify your insurance eligibility.
Birthdate*
Gender*
E-mail*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone*
Alternate phone
Reason for your visit? (select all that apply)*

New patient exam and/or checkupTeeth cleaningInvisalignTeeth whiteningSpecific treatment - e.g. crown, root canal, etc.Urgent issue - e.g. damaged tooth, pain, etc.
Whom may we thank for referring you?*
Which patient referred you?
Please explain how you found out about our office:
Emergency contact name*

First NameLast Name
Emergency contact phone*
Dental insurance information
Insurance provider*
Which insurance do you currently have?*
Subscriber ID #*
Group #
Employment status*
Employer*
College / university name*
Are you interested in learning about our in-house membership plans?

YesNo
Dental history
When it comes to my mouth, I feel...*

Committed - I'm proactive on a daily basisNeutral - I'm pretty casual regarding careUninspired - I have some work to do
The goals I have for my mouth are... (select all that apply)*

Cleaner mouth & fresher breathWhiter teethCavity-free teethTeeth repairStraighter teeth & smileHealthier gums
How do you feel about visiting the dentist? (select all that apply)*

Not at all nervousA little nervousModerately nervousVery nervousExtremely nervous
Date of last dental visit*
Date of last full mouth x-rays*
What, if anything, was performed during your most recent dental visit?
Previous dentist's name & location?
How often do you have dental cleanings?*

Rarely1 time / year2 times / year3 times / year
How often do you brush your teeth?*

Rarely1 time / day2 time / day3 times / day
How often do you floss your teeth?*

RarelyEvery so often1 time / day2 time / day
Are you currently using any other dental aids?
Do you currently have any dental problems we should be made aware of?
Are your teeth sensitive?
While eating something hot or cold?*

YesNo
While eating sweets?*

YesNo
During biting and/or chewing?*

YesNo
Have you noticed any mouth odors or bad tastes recently?*

YesNo
Do you frequently get cold sores, blisters, or oral lesions?*

YesNo
Do your gums bleed or hurt?
Are you currently experiencing gum bleeding or pain?*

YesNo
Have your parents experienced gum disease or tooth loss?*

YesNo
Have you noticed any loose teeth or change in your bite?*

YesNo
Does food tend to become caught in between your teeth?*

YesNo
Do you currently...
Clench or grind your teeth while either awake or asleep?*

YesNo
Bite your lips or cheeks regularly?*

YesNo
Hold objects with your teeth (e.g. pens, pipes, etc.)?*

YesNo
Mouth breath while awake or asleep?*

YesNo
Smoke and/or chew tobacco?*

YesNo
Have you ever had...
Orthodontic/Invisalign treatment?*

YesNo
Oral surgery?*

YesNo
Periodontal treatment?*

YesNo
Your teeth ground or your bite adjusted?*

YesNo
A serious injury to your mouth and/or head?*

YesNo
Have you experienced...
Clicking or popping of your jaw?*

YesNo
Pain (e.g. joint, ear, side of face, etc.)*

YesNo
Difficulty in opening or closing your mouth?*

YesNo
Headaches, neck aches, or shoulder aches?*

YesNo
Sore muscles (e.g. neck, shoulders, etc.)?*

YesNo
Are you satisfied with your teeth?
Would you like to keep all of your original teeth for the rest of your life?*

YesNo
Do you feel nervous about having dental treatment?*

YesNo
Have you ever had an upsetting dental experience?*

YesNo
Is there anything else about having dental treatment that you would like us to know?
Medical history
What is the current estimate of your general health?*
Allergic reactions to... (select all that apply)

Aspirin, ibuprofin, acetaminophen, etc.PenicillinErythromycinTetracyclineSulfaLocal anestheticFluorideMetals (e.g. nickel, gold, silver, etc.)LatexOther
Please explain "Other"*
Are you currently... (select all that apply)

Being treated for other illnessAware of a change in health (e.g. fever, etc.)Taking medication for weight managementTaking dietary supplementsOften exhausted or fatiguedExperiencing frequent headachesA smoker, smoked previously or use tobaccoOften unhappy or depressedFEMALE: Taking birth controlFEMALE: PregnantMALE: Prostate disordersOther
Please explain "Other"*
Do you have or have you ever had... (select all that apply)

Hospitalization for illness or injuryHeart problems/cardiac stent last 6 monthsHistory of infective endocarditisArtificial heart valve, repaired heart defectPacemaker or implantable defibrillatorArtificial prosthesis (heart valve or joints)Rheumatic or scarlet feverHigh or low blood pressureA stroke (taking blood thinners)Anemia or blood disorderProlonged bleeding due to a slight cutEmphysema, sarcoidosisTuberculosisAsthmaBreathing or sleep problems (e.g. apnea, snoring, etc.)Kidney diseaseLiver diseaseJaundiceThyroid or parathyroid diseaseHormone deficiencyHigh cholesterolDiabetesStomach or duodenal ulcerDigestive disorders (e.g. gastric reflux)Osteoporosis/osteopenia (taking bisphosphonates)Arthritis, rheumatoid arthritis, lupusGlaucomaContact lensesHead or neck injuriesEpilepsy, convulsions, seizuresNeurologic disorders (e.g. ADD/ADHD)Viral infections and/or cold soresAny lumps or swelling in the mouthHives, skin rash, hay feverVenereal disease (STI/STD)HepatitisHIV/AIDSTumor, abnormal growthRadiation therapyChemotherapy, immunosuppressive drugsPsychological or behavioral issuesPsychiatric treatmentAntidepressant medicationAlcohol and/or street drug useOther
Please explain "Other"*
Describe any current medical treatment, impending surgery and/or medications you have taken within the last two years:
List all medication, supplements and other vitamins taken within the last two years (drug/purpose):
Please advise us in the future of any change in your medical history and/or any medications you may be taking.
Notice of privacy practices
The privacy of your health is very important to us. The following notice describes how health information about you may be used and disclosed, and how you can get access to this information. Please review it carefully. Our office is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment and health care operations. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination and test results, diagnoses, treatment and applying for future care or treatment. It also includes billing documents for those services.

The health and billing records we maintain are the physical property of Emily Gentry, D.D.S.. You have the following rights with respect to your Protected Health Information:
- Request a restriction on certain uses and disclosures of your health information by delivering the request in writing to our office. Although not required by law, we will comply with any request.
- Obtain a paper copy of the Notice of Privacy practices for Protected Health Information (“Notice”) by making a request at our office.
- Right to inspect and copy your health record and billing record. You may exercise this right by delivering the request in writing to our office using the form we provide you upon request. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practically do so. If you request copies, we may charge a small fee. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format.
- Right to appeal a denial of access to your protected health information, except in certain circumstances.
- You have the right to request that we amend your health information. (Your request must be in writing and it must explain why the information should be amended.) Emily Gentry, D.D.S. is not required to make such amendments. You may file a statement of disagreement if your amendment is denied and require that the request for amendment and any denial be attached in all future disclosures of your protected health information.
- Right to receive an accounting of disclosures of your health information as required to be maintained by law by delivering a written request to our office using the form we provide to you upon request. An accounting will not include internal uses of information for treatment, payment or operations, disclosures made to you or made at your request or disclosures made to family members or friends in the course of providing care.
- Right to confidential communication by requesting that communication of your health information be made by alternative mean or at an alternative location by delivering the request in writing to our office using the form we provide you upon request. If you want to exercise any of the above rights, please contact us at Emily Gentry, D.D.S, 100 Sutter St., Ste. 800, San Francisco, CA 94104 in person or in writing.
Our office is required to…
- Maintain privacy of your health information as required by the Health Insurance Portability and Accountability Act of 1996 (HIPPA).
- Provide you with a notice as to our duties and privacy practices as to the information we collect and maintain about you.
- Abide by the terms of this notice.
- Accommodate your reasonable requests regarding methods to communicate health information with you.
- Accommodate your request for an accounting of disclosures.
We reserve the right to amend, change or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain. If our information practices change, we will amend our notice. You are entitled to receive a revised copy of the notice by calling and requesting a copy of our “notice”, by visiting our office and picking up a copy or by downloading the revised copy from our website at www.gentrydentistry.com.

If you have questions, would like additional information or would like to report a problem regarding the handling of your information, you may contact us at Emily Gentry, D.D.S., 110 Sutter St., Ste. 800, San Francisco, CA 94104. Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our office by delivering the written complaint to us. You may also submit a written complaint to the U.S. Department of Health and Human Services, 200 Independence Ave. SW, Washington, DC 20201. We cannot and will not require you to waive the right to file a complaint with the Secretary of Health and Human Services as a condition of receiving treatment from this office. We cannot and will not retaliate against you for filing a complaint with the Secretary of Health and Human Services.
Cancellation & no-show policy
We respect your time, yet we do have a few basic rules for making and attending appointments. Your time is important, and we will be ready to serve you at a mutually agreed upon day and time. Unlike many medical and dental offices, we do not double book our schedule. This allows you to receive focused and attentive care, but requires everyone be on-time.

Appointments you schedule are reserved especially for you. If you need to reschedule or cancel an appointment, we request and appreciate a minimum of 48 hours’ notice. For the best service for all of our patients, we ask that you make schedule changes during our normal business hours so that we can better reallocate the time to someone else in need of treatment. Appointments cancelled with less than 48 hours’ notice will be automatically charged a fee (to the card listed below) of $100. This fee is not covered by insurance. If you late cancel or no show more than three times then you may be encouraged to seek dental treatment from another provider. A patient who breaks the first office appointment with us is invited to pursue a relationship with another dental office. Exceptions to these rules will be made for large scale natural disasters, such as earthquakes and city-wide power outages.

Hopefully you agree that these rules are fair, and remind all of us to treat each other with basic courtesy and respect.

I authorize the following credit card to be automatically charged for any late cancellations or no shows:
Card type*
Name as it appears on card*

First NameLast Name
Card number*
We will submit a pending $1 test charge to all credit cards.
Card number*
We will submit a pending $1 test charge to all credit cards.
Expiration date*
Security code*
Security code*
Signature of cardholder*
Insurance & financial policy
You are fully responsible for knowing your benefit information. If we are billing your insurance company we will assist you to the best of our abilities with getting your claims paid. However, you are financially responsible for any charges not covered by your insurance plan. Please note that what we collect in the office may only be a portion of your balance. Actual patient responsibility can only be determined once your insurance company has processed a claim. If you have further financial obligation than what we collected in the office, you will receive a statement from our billing company. You are ultimately financially responsible for all services rendered to you. If your account is deferred to a collection agency, you agree to pay all collection costs incurred.

Patients are responsible for costs incurred in their care and financial responsibility must be determined before treatment. All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for at the time services are performed. We accept cash, check, Visa, MasterCard, Discover, American Express and debit cards. There is a $150 charge for returned checks. Patients with dental insurance understand that all dental services rendered are charged directly to the patient, and that the patient is personally responsible for payment of those services. When the patient provides proof of dental coverage for those procedures being performed, then the patient will be charged only the co-payment and deductible at the time services are rendered. It is impossible to accurately determine exact insurance benefits in advance. We will help prepare the patient’s insurance forms or assist in collecting from insurance companies, and will credit any such collections to the patient’s account. Emily Gentry, D.D.S., however, cannot render services on the assumption that total dental fees will be paid by the patient’s insurance company.

All remaining balances over 60 days will be automatically billed to your credit card specified below, unless previous written financial arrangements have been made in advance. Any insurance reimbursement thereafter will be forwarded directly to you. In the event your credit card is denied, a service charge of 1.5% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days.
Payment policy
The policy for patient payment due at Gentry Dentistry is as follows:

Payment at the Time of Service
Patient agrees to pay for the estimated portion due minus any insurance payment (if any) upon check-in each time they are seen at our office. If the patient does not pay for the estimated portion at the time services are rendered, they authorize Gentry Dentistry to automatically charge the payment card specified below.

Automatic End of Month Payment
If there is any amount due after insurance pays the submitted claim, the following credit card on file will be automatically charged at the end of the month for all claims that have been finalized. We will notify all users of any charges and email the patient a statement once any additional charges have been processed.
Which payment card would you like to use?*
Card type*
Name as it appears on card*

First NameLast Name
Card number*
We will submit a pending $1 test charge to all credit cards.
Expiration date*
Security code*
Signature of cardholder*
Signature for approval of payment policy*
Final signature
I have read all of the above information and I understand my responsibility for the payment of my account*
Should be Empty:

Patient name & information

Dental insurance information

Dental history

Are your teeth sensitive?

Do your gums bleed or hurt?

Do you currently...

Have you ever had...

Have you experienced...

Are you satisfied with your teeth?

Medical history

Notice of privacy practices

Cancellation & no-show policy

Insurance & financial policy

Payment policy

Final signature