Fingeret Dental - Registration & Health History Form

First NameMiddle InitialLast Name

MarriedSingleDivorcedWidowed

Full-timePart-timeN/A

Yes, the insured person receiving dental service is the same as above.

Full-timePart-timeRetired

Please enter a valid phone number.

	Yes	No
Rheumatic Fever
Heart Disease
Heart Murmur (or MVP)
High Blood Pressure
Tuberculosis
Use Oral Contraceptives
Artificial Joint/Heart Valve
History of Endocarditis
Thyroid Disease
Anemia
Asthma
Diabetes
Are you nursing?
Might you be pregnant?
Hepatitis
Radiation Therapy: Head/Neck
Seizure Disorder
Kidney Disease
Venereal Disease
Bleeding Problems
Cancer
AIDS/HIV
Eating Disorders

I attest that I understand and answered all the above questions honestly and completely, I understand that the doctor is basing his treatment on this information. | authorize the release of information to Insurance carriers and other health care professionals who are involved in my care. I assign my insurance benefits to Andrew I. Fingeret D.M.D. unless otherwise indicated.

Your signature Indicates you have read the HIPAA law as well as releasing Dr. Fingeret to utilize any dental photographs at his discretion.

Cancellations and Financial Responsibility

Appointments are held exclusively for you. You are required to give "day before" notice of cancellation of an appointment. You can notify us by calling the office or sending an email. Failure to give "day before" notice will incur an office charge of $75. Emergency cancellations are assessed case by case.

I agree to be responsible for all office fees and applicable co-pays at the time of service. In addition if I have dental insurance and my claim is denied for any reason, including exhausting of benefits or failure to meet a deductible, I will be responsible for payment of unpaid services.

Fingeret Dental, Family & Cosmetic Dentistry