PATIENT PAPERWORK

LANGAN DENTAL REGISTRATION AND PATIENT PAPERWORK
PATIENT INFORMAITON
PATIENT NAME *

First NameLast Name
Today's Date*

MonthDayYear
Date
E-MAIL
example@example.com
SOCIAL SECURITY NUMBER:
DRIVERS LICENSE NUMBER:
PLEASE UPLOAD A COPY OF THE FRONT OF YOUR DRIVERS LICENSE/STATE ID:

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Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
GENDER

MALEFEMALE
AGE *
BIRTHDAY*

MonthDayYear
Date
PATIENT EMPLOYER/SCHOOL
OCCUPATION:
MARRIEDSEPERATEDWIDOWEDDIVORCEDSINGLEMINOR
Which office are you going to be a patient at?*
HOW DID YOU HEAR ABOUT US? *
DENTAL INSURANCE

IF YOU DO NOT HAVE DENTAL INSURANCE, PLEASE TYPE "NO INSURANCE" IN THE INSURANCE COMPANY SLOT BELOW - THEN MOVE OF TO THE PHONE NUMBERS SECTION.
PLEASE UPLOAD A COPY OF THE FRONT OF YOUR DENTAL INSURANCE CARD

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PLEASE UPLOAD A COPY OF THE BACK OF YOUR DENTAL INSURANCE CARD

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PRIMARY INSURANCE SUBSCRIBER NAME:
HOW ARE YOU RELEATED TO THE PATIENT: (EX: SELF, MOM, DAD, HUSBAND, WIFE etc...)
PRIMARY INSURANCE COMPANY NAME:
PRIMARY INSURANCE POLICY NUMNER:
PRIMARY INSURANCE GROUP NUMBER:
IS THE PATIENT COVERED BY ADDITIONAL DENTAL INSURANCE OTHER THEN THE ONE LISTED ABOVE?

YESNO
SECONDARY INSURANCE SUBSCRIBER'S NAME:
SECONDARY INSURANCE SUBSCRIBER'S SOCIAL SECURITY NUMBER:
SECONDARY INSURANCE SUBSCRIBER'S BIRTHDAY:

MonthDayYear
Date
SECONDARY INSURANCE COMPANY:
SECONDARY INSURANCE POLICY NUMBER:
SECONDARY INSURANCE GROUP NUMBER:
IF YOU, THE PATIENT, ARE THE SUBSCRIBER OF THE INSURANCE - PLEASE MOVE DOWN THE ASSIGNMENT AND RELEASE.
ASSIGNMENT AND RELEASE
I CERTIFY THAT I, AND OR MY DEPENDENT(S), HAVE INSURANCE COVERAGE WITH THE ABOVE LSITED INSURANCE COMPANY AND ASSIGN DIRECTLY TO DR. LANGAN ALL INSURANCE BENEFITS, IF ANY, OTHERWISE PAYABLE TO ME FOR SERVICES RENDERED. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES WHETHER OT NOT PAID BY INSURANCE. I AUTHORIZE THE USE OF MY SIGNATURE ON ALL INSURANCE SUBMISSIONS.

THE ABOVE-NAMED DENTIST MAY USE MY HEALTH CARE INFORMATION AND MAY DISCLOSE SUCH INFORMATION TO THE ABOVE-NAMES INSURANCE COMPANY(IES) AND THEIR AGENTS FOR THE PURPOSE OF OBTAINING PAYMENT FOR SERVICES AND DETERMING INSURANCE BENEFITS OR THE BENEFITS PAYABLE FOR RELATED SERVICES. THIS CONSENT WILL END WHEN MY CURRENT TREATMENT PLAN IS COMPLETED OR ONE YEAR FROM THE DATE SIGNED BELOW.
SIGNATURE OF PATIENT, PARENT, GUARDIAN OR PERSONAL REPRESENTATIVE: PLEASE SIGN WITH YOUR FINGER OR MOUSE:

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TYPED NAME OF PATIENT, PARENT, GUARDIAN OR PERSONAL REPRESENTATIVE:
Date

MonthDayYear
Date
PHONE NUMBERS
CELL PHONE:
Please enter a valid phone number.
WORK PHONE:
Please enter a valid phone number.
HOME PHONE:
Please enter a valid phone number.
IN CASE OF EMERGENCY CONTACT:
Name

First NameLast Name
RELATIONSHIP:
Phone Number
Please enter a valid phone number.
DENTAL HISTORY
REASON FOR TODAY'S VISIT: *
FORMER DENTIST:
FORMER DENTSIT PHONE NUMBER:
Please enter a valid phone number.
DATE OF LAST DENTAL VISIT:

MonthDayYear
Date
DATE OF LAST DENTAL X-RAYS:

MonthDayYear
Date
PLEASE CHECK ANY OF THE FOLLOWING THAT APPLY TO YOU

BAD BREATHBLEEDING GUMSBLISTARS ON LIPS OR MOUTHBURNING SENSATION ON TOUNGCHEW ON ONE SIDE OF YOUR MOUTHCIGARETTE, PIPE OR CIGAR SMOKINGDRY MOUTHFINGERNAIL BITINGFOOD COLLECTION BETWEEN TEETHCLICKING OR POPPING JAWFOREGIN OBJECTSGRINDING TEETHGUMS SWOLLEN OR TENDERJAW PAIN OR TIREDNESSLIP OR CHEEK BITINGLOOSE TEETH OR BROKEN FILLINGSMOUTH BREATHINGMOUTH PAIN, BRUSHINGORTHODONTIC TREATMENTPAIN AROUND EARSPERIODONTAL TREATMENTSENSATIVITY TO COLDSENSATIVITY TO HEATSENSATIVITY TO SWEETSSENSATIVITY WHEN BITINGSORES OR GROWTHS IN YOUR MOUTH
HOW OFTEN DO YOU FLOSS?
HOW OFTEN DO YOU BRUSH?
HEALTH HISTORY
PHYSICIAN'S NAME:
PHYSICIAN'S PHONE NUMBER:
DATE OF LAST VISIT:

MonthDayYear
Date
HAVE YOU EVER USED A BISPHOSPHONATE MEDICATION? COMMON BRAND NAMES ARE FOSAMAX, ACTONEL, ATELVIA, DIDRONEL, BONIVA

NOYES
HAVE YOU EVER TAKEN ANY OF THE GROUP DRUGS COLLECTIVELY REFERRED TO AS "FEN-PHEN"? THESE INCLUDE COMBINATIONS OR LONIMIN, ADIPEX, FASTIN (BRAND NAMES OF PHENTERMINE), PONDIMIN (FENFLURAMINE) AND REDUX (DEXFENFLURAMINE).

YESNO
PLEASE MARK TO INDICATE IF YOU HAVE HAD ANY OF THE FOLLOWING:

AIDS/HIVANEMIAARTHRITIS, REHUMATISMARTIFICIAL HEART VALVESARTIFICAL JOINTSASTHMABACK PROBLEMSBLEEDING ABNORMALLY WITH EXTRACTIONS OR SURGERYBLOOD DISORDERCANCERCHEMICAL DEPENDENCYCHEMOTHERAPYCIRCULATORY PROBLEMSCONGENITAL HEART LESIONSCOUGH, PERSISTENT OR BLOODYCORTISONE TREATMENTSDIABETESEMPHYSEMAEPILEPSYFAINTING OR DIZZINESSGLAUCOMAHEADACHESHEART MURMURHEART PROBLEMSHERPESHIGH BLOOD PRESSUREJAUNDICEJAW PAINKIDNEY DISEASELIVER DISEASELOW BLOOD PRESSUREMITRAL VALVE PROLAPSENERVOUS PROBLEMSPACEMAKERPSYCHIATRIC CARERADIATION TREATMENTRESPIRATORY DISEASERHEUMATIC FEVERSCARLET FEVERSHORTNESS OR BREATHSINUS TROUBLESKIN RASHSPECIAL DIETSTROKESWOLLEN FEET OR ANKLESSWOLLEN NECK GLANDSTHYROID PROBLEMSTONSILLITISTUBERCULOSISTUMOR OR GROWTH ON HEAD OR NECKULCERVENEREAL DISEASEWEIGHT LOSS, UNEXPLAINED
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*

YES I PREMEDNO I DON'T PRE MEDI DON'T KNOWI DON'T HAVE ANY ARTFICAL JOINTS/HEART VALVE REPLACEMENT
FOR WOMEN: ARE YOU PREGANT?

YESNO
DO YOU TAKE A BLOOD THINNER?*

YESNO
IF YOU ARE PREGNANT - YOU MUST HAVE YOUR OBGYN FAX US DENTAL CLEARANCE TO 570-319-9754 OR EMAIL LANGANDENTALGROUP@GMAIL.COM
DUE DATE:

MonthDayYear
Date
ARE YOU NURSING?

YESNO
TAKING BIRTH CONTROL?

YESNO
MEDICATIONS
PLEASE LIST ANY MEDICATIONS YOU ARE CURRENTLY TAKING AND THE CORRELATING DIAGNOISI. IF YOU ARE NOT ON ANY PLEASE PUT "NONE". **YOU CAN ALSO UPLOAD A PICTURE OF YOUR LISTED MEDICATIONS BELOW IF YOU RUN OUT OF ROOM** *
MEDICATION UPLOAD PICTURE OPTION:

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PHARMACY PHONE NUMBER:
Please enter a valid phone number.
PLEASE LIST ANY NEW DISEASES & MEDICAL CONDITIONS/ SURGERIES WITH SURGERY DATE:IF NONE, PLEASE TYPE NONE.
ALLGERIES
PLEASE CHECK ANY THAT APPLY TO YOU:

ASPRINAMOXICILLINBARBITURATES (SLEEPINGPILLS)CODEINELODINELOCAL ANESTHETICPENICILLINSULFALATEXOther
PATIENT FORM
PATIENT'S NAME*

First NameLast Name
PATIENT'S BIRTHDAY *

MonthDayYear
Date
BEST PHONE NUMBER TO CALL / TEXT TO CONFIRM APPOINTMENTS
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
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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Date*

MonthDayYear
Date
HIPAA 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 for the name. (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 Plainings, Crown’s, 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, brushing, discomfort, stiff jaws, infections, aspiration, paresthesia, nerve disturbance or damage either temporary or permanent, adverse drug response, allergic reaction, and cardiac arrest.
Signature*

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Date*

MonthDayYear
Date
CANCELLATION 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, GOVERNMENT 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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PATENT/GUARDIAN SIGNATURE

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PHARMACY NAME & CITY LOCATED: *
Should be Empty:

LANGAN DENTAL REGISTRATION AND PATIENT PAPERWORK

PATIENT INFORMAITON

DENTAL INSURANCE

IF YOU, THE PATIENT, ARE THE SUBSCRIBER OF THE INSURANCE - PLEASE MOVE DOWN THE ASSIGNMENT AND RELEASE.

ASSIGNMENT AND RELEASE

PHONE NUMBERS

DENTAL HISTORY

HEALTH HISTORY

MEDICATIONS

ALLGERIES

BEST PHONE NUMBER TO CALL / TEXT TO CONFIRM APPOINTMENTS

RADIOGRAPHS & CLINICAL RECORDS RELEASE

ASSIGNMENT OF BENEFITS FOR INSURANCE REIMBURSEMENT

INFORMED CONSENT FOR THE TREATMENT OF CONDITIONS AND EXPLANATIONS HAVE BEEN REVIEWED