New Patient Registration Form Step 1 of 4 25% Patient Information *All fields requiredPatient Name: TitleDr.MissMr.Mrs.Ms.Prof.Rev. Prefix First Middle Last Suffix Family Status:--select--MarriedSingleChildOtherGender--select--MaleFemaleSSN# Birth Date: MM slash DD slash YYYY Email Address: Best time to call: Phone:Address Street Address Address Line 2 City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Which location are you interested in scheduling at? Huron Parkway West Stadium Golfside Pediatrics Do you have a preference on which doctor you will be seeing? Yes No Please select the doctor:Dr. KennedyDr. MarzonieDr. GrayDr. E. K. MarlowDr. DiDonatoDr. GarciaDr. A. MarlowDr. RacelisDr. Hoffman (Diplomate of Pediatric Dentistry)Dr. ReichlmayrAre you having any issues or concerns that you would like addressed with one of our doctors? Pain Sensitivity Second opinion Have you been diagnosed with gum disease? Yes No Date of your last visit to the dentist and what were you seen for and when was your last dental cleaning appointment? (If you can’t remember, please give a rough estimate): Do you require antibiotics before having an appointment? Yes No It is likely we will be taking x-rays for your initial appointment. Is there any chance you could be pregnant? Yes No What is your occupation? Who referred you/ How did you hear about our office? What is the main reason for your dental appointment? Primary Insurance InformationDo you have dental Insurance? Yes No Name of insured: First Middle Last Patient’s relationship to insured:--select--SelfSpouseChildOtherInsurance Plan Name: Social Security Number of insurance subscriber: Employer of insurance subscriber: Insurance ID of insurance subscriber: Birth Date of insurance subscriber: Secondary Insurance InformationDo you have secondary dental Insurance? Yes No Name of insured: First Middle Last Patient’s relationship to insured:--select--SelfSpouseChildOtherInsurance Plan Name: Social Security Number of insurance subscriber: Employer of insurance subscriber: Insurance ID of insurance subscriber: Birth Date of insurance subscriber: New Patient Medical History FormPatient Name: First Middle Last Suffix Email DOB: MM slash DD slash YYYY In the event of any emergency who is the closest relative we can contact?Emergency Contact Name Relationship Phone NumberDental History When was the last time you had your teeth cleaned? MM slash DD slash YYYY Do you experience Dental Anxiety? Yes No Please describe. Is there any way we can make you more comfortable?Are you aware of any dental problems? Yes No If so, what?Medical History Do you have a primary care physician?* Yes No If so, whom?When was your last visit?* MM slash DD slash YYYY Have you had any problems in your general health in the past 5 years? Serious illness, hospitalization, surgery, etc…* Yes No If so, please describePlease list all medications you are currently taking (including all prescriptions and OTC medications and supplements [i.e. medical marijuana, vitamins, etc]):Do you require Pre-Medication prior to your dental visits?* Yes No If so, please describeDo you have any of the following diseases or conditions?* Allergy - Aspirin Allergy - Codeine Allergy - Latex Allergy - Other Allergy - Seasonal Allergy - Sulfa Allergy - Tree Nut Anemia Arthritis Artificial Joints Asthma Blood Disease Cancer Diabetes Dizziness Epilepsy Excessive Bleeding Fainting Glaucoma Head Injuries Heart Attack Heart Disease Heart Valve Conditions Hepatitis High Blood Pressure HIV or AIDS Jaundice Kidney Disease Liver Disease Low Blood Pressure Neck/Back Conditions Nervous System Conditions Osteoporosis Pacemaker Psychiatric Conditions Radiation Treatment Respiratory Conditions Sleep Apnea Sinus Conditions Stomach Conditions Stroke Thyroid Disorders Tuberculosis Tumors Ulcers Venereal Disease None of The Above Please describe conditions listed above in as much detail as possible:*Do you have any disease, condition, problem or allergies not listed above that you think the doctor should know about? If so, please describe:*Do you have an allergy or sensitivity to any antibiotics? If so, please list:*Please list all medications you are currently taking (including all prescriptions and OTC medications and supplements [i.e. medical marijuana, vitamins, etc]):*Are you currently pregnant?* Yes No Due Date MM slash DD slash YYYY Do you smoke, vape or use any tobacco products?* Yes No If so, what kind and how often?Do you drink alcohol or use recreational drugs?* Yes No If so, what kind and how often?Do you experience any jaw pain?* Yes No If so, please describe:Do you snore?* Yes No If so, please describe:Have you ever participated in a sleep study?* Yes No If so, please describe:Are you interested in discussing any of the following:* Botox or Dermal Filler Braces/Invisalign Dental Implants Sedation for Dental Visits Sleep Apnea Alternatives to CPAP Tooth Replacement (bridges, partial dentures, etc) Veneers/ Cosmetic Dentistry Wisdom Teeth Whitening Other: Please describe I acknowledge that I have reviewed ALL questions/alerts on this questionnaire and responded accordingly. There are no other medical conditions or medications/allergies that have not been listed. I am aware that I must notify the practice of any future changes. Signature*Date* MM slash DD slash YYYY Staff Initials: Patient Acknowledgement and Consent Form Effective April 14, 2003, the federal law known as the Health Insurance Portability and Accountability Act of 1966 (“HIPAA”) requires that this office comply with certain rules regarding the maintenance of the privacy of your information that we have collected and will collect in the future. To comply with one of HIPAA’s requirements, we are giving you a copy of our Notice of Privacy Practices. The Notice of Privacy Practices contains the information that HIPAA requires us to disclose regarding our privacy practices. Existing Michigan Law requires (in addition to our attempt to obtain your written acknowledgement, discussed above) us to first obtain your written consent prior to disclosing any of your information except for our disclosures in connection with: a defense to clain challenging out professional competence; a review entity’s functions; a claim for payment of fees; a third party payer’s examination of our records; a court order as part of a crimanal investigation; an identification of a dead body; a liscense investigation; or a child abuse/neglect investigation. From time to time it may be necessary for us to make disclosures of your information in connection with your treatment. For example, we may make a referral to or consult with another dentist or health care professional, provide a specimen to a laboratory for testing or otherwise make disclosures of your information in connection with providing or coordinating your treatment. Do you acknowledge that you have received a copy of our notice of privacy practice? Yes No Do you consent to our disclosure of your information that we deem necessary in order to provide you with proper treatment? Yes No Print Name: SignatureDate MM slash DD slash YYYY Patient Responsibility Agreement Payment is expected at the Time of Service For all patients, payment of insurance co-pays, deductibles, and services not covered by insurance are to be paid for at the time services are rendered. You are responsible for any balances not covered by your insurance, including rejected claims. While every effort will be made to submit claims in accordance with insurers’ requirement for payment, in the event of a dispute or rejection, you as the insured or guarantor are responsible for payment. Insurance coverage for dental services is a benefit provided to you and the eligible members of your family. The insurance contract is between you and your insurance provider, and not between the insurance company and your dental care provider. It is very unlikely for our dental office staff to predict exactly what your benefits are, since there are so many different insurers and policies. We will do our best to obtain correct information, but we are not responsible for misinformation given by your insurer. Also, be made aware that each insurance policy has a maximum allowed during the contract period. We cannot be held responsible for tracking this information for you. We do not accept Medicaid of MIDA as a form of payment. Also, there are other capitation and HMO insurers for which we are not an authorized provider. You are responsible for checking your plans list of providers ahead of time. If we are not a provider on that list, you will be responsible for payment yourself. We will be happy to provide you with whatever documentation is necessary to pursue your claim for reimbursement for your insurance company. Payment Responsibility for Divorced / Separated Parents The person who brought the child in for services is responsible for payment. This office cannot be responsible for payment. This office cannot be responsible for collecting from any other individual. Missed or Cancelled Appointment Policy Patients will be charged $50.00 per appointment for failed or cancelled hygiene appointments with less than one business day’s notice. Patients will be charged $100.00 per appointment for failed or cancelled doctor appointments with less than one business day’s notice. Failed or cancelled appointment fees are doubled for evening (5:00 pm or later) and weekend appointments due to high demand and limited availability. The failed or cancelled appointment fee must be paid before the patient can schedule another appointment. Insurance companies do not cover failed or cancelled appointment fee. The patient is responsible to pay the failed or cancelled appointment fee. I acknowledge that I have read and understand this payment policy.Print Name: SignatureDate MM slash DD slash YYYY CAPTCHANameThis field is for validation purposes and should be left unchanged. FollowFollowFollowFollow © Ann Arbor Smiles Dental Group 2020 | Sitemap | Site Map
