Dental Patient Registration Form - Summerhill Dentist 4166721000

Where did you hear about us?

In case of emergency please contact:

Emergency Contact Number

WORK INFORMATION

INSURANCE INFORMATION

Date of Birth (YYYY-MM-DD)

Group / Policy Number

ID / Certificate Number

If covered under spouse’s plan as secondary coverage:

Date of Birth (YYYY-MM-DD)

Group / Policy Number

ID / Certificate Number

Address of Physician

Are you currently under medical treatment?

Yes No

Have you had an allergic or unusual reaction to any of the following?
(Leave blank if all answers are No)

Dental Anesthetic

Yes No

Are you Pregnant?

Yes No

If yes, Expected date of delivery

Have you ever been treated for any of the following?
(Leave Blank if all answers are No)

Heart Murmurs

Yes No

Kidney Disease

Yes No

Rheumatic Fever

Yes No

Sinus Trouble

Yes No

Venereal Disease

Yes No

Please answer all questions below:

Have you ever been treated for AIDS-related complex?

Yes No

Are you taking any medications? If so, what are they?

Yes No

Do you have heart trouble? If so, what kind?

Yes No

Do you have high or low blood pressure? Is it controlled?

Yes No

Have you ever been required to take prophylactic antibiotics prior to dental treatment?

Yes No

Do you use tobacco products? If so, how often?

Yes No

Are you subject to fainting or dizziness? If so, how often?

Yes No

Have you ever had cancer or a tumor? If so, how was it treated?

Yes No

Have you ever had any major operations? If so, what kind?

Yes No

Have you ever been involved in a serious accident?

Yes No

Do you bruise or bleed easily?

Yes No

Have you recently had a communicable disease (i.e. Mumps, Measles, etc.)?

Yes No

In past years have you been to a dentist on a regular basis? If so how often?

Are you presently in any dental pain?

Is any part of your mouth sensitive to temperature, pressure or sweets?

Do you have an unpleasant taste or odor in your mouth?

Have you ever gotten food stuck between your teeth?

Do you awaken with pain in your teeth or jaws?

Do you have frequent headaches or facial pain?

Are you aware of jaw clicking or popping while eating or yawning?

Do you ever get cold sores or fever blisters?

What is your major dental concern at this time?

PLEASE READ THE FOLLOWING CAREFULLY

Office Policy

We will gladly complete Dental Insurance Claim Forms with the following understanding;
a) The patient is financially responsible for the entire cost of the treatment.
b) Payment is to be made to “Dental Land Professional Corporation” by the patient or by direct billing to the insurance company.

iTrans

Benefits payable from claims submitted electronically will be assigned to Dental Land and payment will be received by the Dentist directly.

CANCELLATION/ NO SHOW POLICY

At least 24 hours notice is required if you must cancel/reschedule your appointment for any reason.
Missed Appointments will incur a firm charge of $50.00
All outstanding fees must be paid in full before further appointments will be booked.
Should you miss an appointment, it is your responsibility to call and rebook.
Frequent or numerous cancellations and/or no shows will result in permanent discharge from the practice.

Statement of Understanding
I hereby acknowledge and confirm that I have read the policy stated above. I agree to conduct my activities in accordance with Dental Land Professional Corporation's policy and understand that breaching it in anyway may result in disciplinary action.

By checking this checkbox, I hereby understand and agree to the conditions mentioned above.

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