REGISTRATION AND TREATMENT

REGISTRATION AND TREATMENT
Date

MonthDayYear
Date
PATIENT INFORMATION
Name*

First NameLast Name
Modie intial
E mail*
example@example.com
Social Security #
For Insurance
Address*
City*
State*
Zip*
Age
Birthdate*

MonthDayYear
Date
Patient Employer/School
Mobile Phone*
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Occupation
Employer/School Address
Whom may we thank for referring you?

GoogleInsuranceWebsiteZocdocFriend>NameOther
In case of emergency who should be notified?
Name and Relationship to Patient
Phone
PRIMARY INSURANCE
Person Responsible for Account
Name

First NameLast Name
Relation to Patient
Birthdate

MonthDayYear
Date
Social Security / Subscriber ID
Address (If different from patient's),
City
State
Zip
Person Responsible Employed By
Occupation
Insurance Company
Contract # (if applicable)
Insurance Contact Information
Group .
Subscriber / ID #
Names of other dependents covered under this plan
ADDITIONAL INSURANCE
DENTAL HISTORY
Reason for Today's Visit
Date of last dental care

MonthDayYear
Date
Former Dentist
Address
Date of last dental X rays

MonthDayYear
Date
Check if you have had problems with any of the following

Bab breathBleeding gumsClicking or Popping JawFood Collections between TeethGrinding TeethLoose teeth or broken fillings
Check if you have had problems with any of the following

Periodontal treatmentSensitivity to coldSensitivity to hotSensitivity to sweetsSensitivity when bitingSores or growths in you mouth
How often do you brush?
How often do you floss?
MEDICAL HISTORY
Physician's Name
Date of Last Visit

MonthDayYear
Date
Have you had any serious illnesses or operations? If Yes, explain:
Have You ever had a blood transfusion? If Yes, give aproximate dates.

MonthDayYear
Date
Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of Ionimin, Adipex, Fastin, phentermine, pondimin (fenfluramine) and Redux (dexfentluramine)

YesNo
(Women) Are you pregrant?

YesNo
Nursing?

YEsNO
Taking birth control?

YesNo
Chech (x) if you have or have had any of the following

AnemiaArthritis, RheumatismArtificial Heart ValvesArtificial JointsAsthmaBack ProblemsBlood DiseaseCancerChemical DependencyChemotherapyCirculatory Problems
Coritsone TreatmentsCough, PersistantCough up BloodDiabetesEpilepsyFaintingGlaucomaHeadachesHeart MurmurHeart ProblemsHemophilia
Chech (x) if you have or have had any of the following

HepatitisHigh Blood PressureHIV/AIDSJaw PainKidney DiseaseLiver DiseaseMitral Valve ProlapsePacemakerRadiation TreatmentRespiratory DiseaseRheumatic Fever
Scarlet FeverShortness of BreathSkin RashStrokeSwelling of Feet or AnklesThyroid ProblemsTobacco HabitTonsillitisTuberculosisUlcerVenereal Disease
Other Medical Conditions not listed
List MEDICATIONS you are currently taking
Allergies To Medications, Latex, Lidocaine or others:
AUTHORIZATION
I certify that I and/or my dependent(s have insurance coverage with
Name of insurance Company(ies)
and assign insurance benefits, if any, otherwise payable to me for services rendered directly to Boutique Dental. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above-named dentist/entity may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services.
Dental Insurance Assignments of Benefits to:*
Signature of Patient, Parent, Guardian or Personal Representative*

Clear
Date*

MonthDayYear
Date
Please print name of Patient, Parent, Guardian or Personal Representative*
Relationship to Patient*
Payment is due in full at time of treatment unless prior arrangements have been approved.
FINANCIAL POLICY
Payment is expected at the time of service. For your convenience, we do accept Master Card, Visa, and American Express, Zelle, Check and Cash. We ask our patients to give at least 48-24 hours' notice if they must cancel an appointment. We reserve the right to charge your account a missed appointment fee of $100.00. A$25.00 returned check fee will be assessed to your account for all returned checks.

We will contact your insurance company for you and determine as close as is possible what your portion is to pay on the date service. This information is on estimate only and we cannot guarantee any information to your insurance company on your behalf. After your insurance company pays their portion, we will inform you of what balance, if any, is outstanding for you to pay. This amount will be due upon notification.

Please note that your insurance policy is a contract between you and your insurance carrier. It is your responsibility to understand your plan benefits. If for any reason your insurance carrier does not pay within forty-five days, as allowed by law, the balance will become your responsibility. This balance will be assessed monthly interest charges of 5% if not paid upon receipt of your statement. In the unfortunate circumstance that your account becomes more than 90 days overdue, your account will be forwarded to Credit Services, our collection agency, your account will also be charged an additional collection fee of $50.00

Credit/Debit Card Payments carry 4% convenience fee.
I consent to diagnostic precedures and treatment by the dentist necessary for proper care.*

< Check
I consent to the dentist's use and disclosure of my records (or my child's records) to carry out treatment, to obtain payment, and for those activities and healthcare operations that are related to treament or payment.*

< Check
Our staff is available to answer any questions that you may have regarding our financial policy.

By my signature, I have read and understood the fincial and consent policy of this office. If I request to enter into a payment plan or financing of any sort, I hereby give my permission to have this office retrieve a credit report on me. In cases where the payment is being received directly from the insurance company, I authorize payment to this office.
Signature (Parent or Guardian signature required if the patient is minor)*

Clear
Date*

MonthDayYear
Date
Patients HIPAA Awareness

With my permission, Glendale Boutique Dental, may use and disclose Protected Health Information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). Please refer to Glendale Boutique Dental’s notice of privacy Practices a more complete description of such uses and disclosures.

I have the right to review the Notice of Privacy Practices prior to signing the consent. Glendale Boutique Dental reserves the right to revise its Notice of Privacy Practice at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to the Privacy Officer.

With my permission, the office of Glendale Boutique Dental may call my home or other designated locations and leave message on a voice mail or in person in reference to any items that assist the practice in carrying out TPO. Such include appointment reminders, insurance items, laboratory results and any calls pertaining to clinical care.

With my permission the office of Glendale Boutique Dental may email my home or other designated location and carry out other TPO such as appointment reminder cards and patient statements. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound to this agreement.

By signing this I am allowing Glendale Boutique Dental to use and disclose my PHI for THO. I may revoke my consent in writing and the practice will not disclose information from the date of the revocation. Any Disclosures made prior to revocation will be under this consent.
Signature of Patient or Legal Guardian*

Clear
Print Name of Patient or Legal Guardian*
Date*

MonthDayYear
Date
Upload Files (Dental Insurance card font and back, as well as Patient/Guardian ID)

Cancelof
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REGISTRATION AND TREATMENT

PATIENT INFORMATION

PRIMARY INSURANCE

ADDITIONAL INSURANCE

DENTAL HISTORY

MEDICAL HISTORY

AUTHORIZATION

FINANCIAL POLICY