modernendodontics.net - Patient Registration

PATIENT REGISTRATION
PATIENT INFORMATION
Name*

First NameMiddle NameLast Name
Preferred Name:*
DOB: *

MonthDayYear
Date
SS#:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone:*
Please enter a valid phone number.
Work Phone:*
Please enter a valid phone number.
Cell Phone: *
Please enter a valid phone number.
Email Address:*
example@example.com
Referred by:*
***MODERN ENDODONTICS REQUIRES THE USE OF YOUR SOCIAL SECURITY IN ORDER TO SUBMIT CLAIMS. IF PREFER TO NOT COMPLY, THEN WE WILL REQUIRE PAYMENT IN FULL AND PROVIDE THE
INFORMATION FOR YOU TO SUBMIT YOUR OWN CLAIMS. THANK YOU FOR UNDERSTANDING***
Are you:*

MarriedSingleDivorcedWidowed
RESPONSIBLE PARTY INFORMATION: (If patient is younger than 18 years old)
Younger than 18 years old

YesNo
Name*

First NameMiddle NameLast Name
Preferred Name: *
DOB:*

MonthDayYear
Date
SS#:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*
Please enter a valid phone number.
Work Phone:*
Please enter a valid phone number.
Cell Phone:*
Please enter a valid phone number.
Email Address:*
example@example.com
Emergency Contact – Name*
Emergency Contact – phone:*
Please enter a valid phone number.
Primary dentist/dental practice:*
Local pharmacy:*
DENTAL BENEFIT INFORMATION:

As a courtesy to our patients with dental benefits, we submit claims to your dental carrier. We make every effort to accurately estimate your treatment, however, due to a variety of factors we cannot guarantee what coverage dental carriers will provide. To assist you with this, we need ALL of the information requested below.

Please be sure to thoroughly review the financial policy included in your new patient paperwork, especially as it pertains to dental benefits. Our administrative team is happy to answer any questions you may have.
DENTAL BENEFIT INFORMATION

YesNo
Policy Holder:*
Policy Holder DOB:*
Policy Holder SS#:
Dental Carrier: *
Subscriber ID #:*
Group #:*
Provider Relations phone: *
Employer:*
SECONDARY DENTAL BENEFIT INFORMATION:
SECONDARY DENTAL BENEFIT INFORMATION:

YesNo
Policy Holder: *
Policy Holder DOB:*
Policy Holder SS#:*
Dental Carrier:*
Subscriber ID #:*
Group #: *
Provider relations phone:*
Employer:*
On a scale of 1 – 10, 10 being the most 1 being the least, how nervous are you about dental visits?
Is there any information that you would like to share with Dr. Mirucki or that you feel he should know?
Patient Signature:*

Clear
Date: *

MonthDayYear
Date
Parent/Guardian Signature:(If applicable) *

Clear
Medical History
Patient Name: *
Birth Date: *

MonthDayYear
Date
Date Created:*

MonthDayYear
Date
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.
Are you under a physician's care now?*

YesNo
Physician's Name:*
Have you been hospitalized or had a major operation in the last 2 years?*

YesNo
Please describe operation:*
Have you ever had a serious head or neck injury?*

YesNo
Please describe head or neck injury:*
Are you taking any medications, pills, or drugs?*

YesNo
Please list medications, pills, or drugs:*
Have you ever taken Fosamax, Boniva, Actonel or any other mediations containing bisphosphonates?*

YesNo
Please list other medications:*
Do you use tobacco?*

YesNo
Women: Are you...

Pregnant/Trying to get pregnant?Nursing?Taking oral contraceptives?
Are you allergic to any of the following?*

AspirinPenicillinCodeineAcrylicMetalLatexSulfa DrugsLocal AnestheticsOther?No
If yes*
Do you use controlled substances?*

YesNo
If yes*

Do you have, or have you had, any of the following? *

	Yes	No
AIDS/HIV Positive
Diabetes
Hepatitis B or C
Rheumatic Fever
Rheumatism
Artificial Heart Valve
Hypoglycemia
Irregular Heartbeat
Spina Bifida
Liver Disease
Glaucoma
Mitral Valve Prolapse
Cold Sores/Fever Blisters
Congenital Heart Disorder
Heart Trouble/Disease
Hemophilia
Hepatitis A
Renal Dialysis
Angina
Arthritis/Gout
Excessive Bleeding
Sickle Cell Disease
Sinus Trouble
Leukemia
Stroke
Lung Disease
Heart Attack/Failure
Heart Murmur
Heart Pacemaker
Psychiatric Care
Radiation Treatment
Anaphylaxis
Anemia
Emphysema
Epilepsy or Seizures
Shingles
Asthma
Blood Disease
Stomach/Intestinal Disease
Low Blood Pressure
Thyroid Disease
Osteoporosis
Pain in Jaw Joints
Parathyroid Disease
Alzheimer's Disease
Drug Addiction
Herpes
High Blood Pressure
High Cholesterol
Artifical Joint
Fainting Spells/Dizziness
kidney Problems
Frequent Headaches
Cancer
Chemotherapy
Tuberculosis
Tumors or Growths
Convulsions

Have you ever had any serious illness not listed above?*

YesNo
If yes*
Dental Questions

What is the reason for today's visit? (Please check all that apply)
Pain*

YesNo
Sensitive to Hot*

YesNo
Sensitive to Cold*

YesNo
Sensitive to Biting or Chewing *

YesNo
Comments*
Should be Empty:

PATIENT REGISTRATION

SECONDARY DENTAL BENEFIT INFORMATION:

Medical History

Dental Questions