Adult General And Family Dentistry Registration Form

PATIENT REGISTRATION

First Name *

Middle Name *

Last Name *

Preferred Name

PATIENT INFORMATION

Address *

City *

State *

Zip *

Cell Phone *

Home Phone

Work Phone

Email *

Best way to confirm your appointment *

For Insurance Purposes - Marital Status *

Birth Date *

Age *

Social Security Number *

Emergency Contact Name *

Relation to Patient *

Emergency Phone Number *

How were you referred to our office? *

Name of Previous Dentist *

Previous Dental Office *

Date of Last Visit *

Date of Last Cleaning *

PRIMARY INSURANCE INFORMATION

Name of Policy Holder *

Policy Holder ID *

Birth Date *

Social Security Number *

Relationship to Policy Holder *

Insurance Company *

Insurance Phone Number *

Policy Holder Employer *

Policy Group Number *

SECONDARY INSURANCE INFORMATION

Name of Policy Holder

Policy Holder ID

Birth Date

Social Security Number

Relationship to Policy Holder

Insurance Company

Insurance Phone Number

Policy Holder Employer

Policy Group Number

MEDICAL HISTORY

Are you taking any prescriptions and/or over the counter medications or vitamin supplements at this time? *

If yes, please list the medications

Are you allergic to any medications, i.e.; penicillin, antibiotics or other drugs? *

If YES, please explain

Are you allergic to anything else, such as foods? *

If YES, please explain

Have you ever had a serious illness? *

If YES, please explain

Have you ever been hospitalized? *

If YES, please explain *

Are you being treated for any illnesses? *

If YES, please explain *

Have you ever received a general anesthetic? *

Do you have any speech difficulties? *

Do you have any inherited problems? *

If YES, please explain

Have you ever had a blood transfusion? *

Are you physically, mentally or emotionally impaired? *

Have you been diagnosed with ADHD or Autism? *

Do you experience excessive bleeding when cut? *

DENTAL HISTORY

Do your gums bleed while brushing or flossing? *

Are your teeth sensitive to hot or cold liquid/foods? *

Are your teeth sensitive to sweet or sour liquids/foods? *

Do you feel pain to any of your teeth? *

Have you had any head, neck or jaw injuries? *

Do you like your smile? *

Have you ever experienced the following with your jaw:

Clicking? *

Pain (joint, ear, side of face)? *

Difficulty in opening or closing? *

Difficulty chewing? *

Do you have frequent headaches? *

Do you clench or grind your teeth? *

Do you bite your lips or cheeks frequently? *

Would you like to know more about the therapeutic and cosmetic benefits of Botox? *

Have you ever experienced difficult extractions? *

Have you ever experienced prolonged bleeding following extractions? *

Have you had any orthodontic (braces) treatment? *

Are you interested in cosmetic dentistry or FastBraces? *

Do you wear partials or dentures? *

If yes, how old are they? *

Are you apprehensive or anxious when visiting the dentist? *

If yes, would you like to know more about Sedation? *

HIPPA

1. I understand that acceptance of this agreement means I am solely responsible for payment of the total cost of service regardless of any limitations of my insurance coverage. We will file a pre-treatment estimate with your insurance company at your request.

2. The patient's estimated portion is based only on the benefit information from your insurance. It is not a guarantee of actual benefit payment. All estimated co-pays and deductibles are due at the time of service.

3. Interest-free financing is also available after qualifying.

4. A finance charge of 1.25% (15%APR), per month with a minimum charge of $.50 per month will be applicable on account balances after 90 days.

5. According to the HIPPA guidelines, Fifth Avenue Dental has my permission to submit dental claims to my insurance and referral doctors. Contact us for a copy.

6. Fifth Avenue Dental only discloses personal information for the reasons listed above.

7. Fifth Avenue Dental confirms appointments via text, email, or auto-dial.

I acknowledge that I have read and understood this agreement and agree to the terms stated above.

HIPPA Signature *

Clear

Today's Date *

FIFTH AVENUE DENTAL RECORD RELEASE

Please release dental records for the following patients:

Name *

DOB *

Name *

DOB *

Please e-mail all chart records and digital radiographs to:
office@anokafifthavedental.com

Signature *

Clear

Today's Date *

reCAPTCHA

Adult Registration Form

Your dedicated family dentist in the heart of Historic Downtown Anoka

PATIENT REGISTRATION

PATIENT INFORMATION

PRIMARY INSURANCE INFORMATION

SECONDARY INSURANCE INFORMATION

MEDICAL HISTORY

DENTAL HISTORY

HIPPA

FIFTH AVENUE DENTAL RECORD RELEASE

CONTACT

BUSINESS HOURS

SERVICES