PATIENT REGISTRATION
Patient Information
Patient name
Date of birth
Age
Date
Gender
Male
Female
Marital status
Single
Married
Separated
Divorced
Widowed
Minor
Minor: Parent’s name
How do you wish to be addressed?
Residence - address
City
State
Zip
Same as mailing address?
Yes
No
Mailing address
City
State
Zip
Phone - residence
Business
Cell
Email
Patient/Parent employer
Spouse/Parent name
Spouse employer
Who is responsible for this account?
Drivers license no.
Purpose of visit
Other family members who are patients in this practice
Whom may we thank for this referral?
Someone to notify in case of emergency not living with you
Dental Insurance
Are you covered by dental insurance?
Yes
No
Employee name
Date of birth
Relationship to patient
Employer name
Insurance Co. name
Address
City
State
Zip
Phone
Member ID
Social security no.
Group no.
Do you have secondary dental insurance?
Yes
No
Employee name
Date of birth
Relationship to patient
Employer name
Insurance Co. name
Address
City
State
Zip
Phone
Member ID
Social security no.
Group no.
Consent
I consent to the diagnostic procedures and treatment by the dentist necessary for proper dental care.
I consent to the dentist’s use and disclosure of my records (or my child’s records) to carry out treatment, to obtain payment, and for those activities and health care operations that are related to treatment or payment.
I consent to the disclosure of my records (or my child’s records) to
the following persons
who are involved in my care (or my child’s care) or payment for that care.
My consent to disclosure of records shall be effective until I revoke it in writing.
Signature of Patient or Legal Guardian
–
Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Date
Financial and Office Policies Agreement
At Eagle Run West Dental Group, we strive to provide high-quality dental care and maintain transparent financial policies for all our patients. Please carefully review the following terms, which apply to all financial transactions at our office.
Payment Options
We accept cash, checks and all major credit cards (Visa, MasterCard, Discover, American Express) and CareCredit Financing.
A 2.99% processing fee will be applied to all card payments.
Insurance Policy
As a courtesy to our patients, we submit claims to most insurance companies. However, we do not submit claims to Medicaid.
Please note that we cannot guarantee payment or coverage from your insurance provider. Ultimately, the responsible party is accountable for any remaining balance on the account.
Missed Appointments and Late Cancellations
A $50 fee will be charged for any missed appointments or for appointments canceled without providing at least 24 hours’ notice.
Finance Charges
A finance charge will be applied to outstanding balances at the rate of 1.33% per month, which is equivalent to an annual percentage rate (APR) of 16%.
Delinquent Accounts
If no payment is received on an account for 90 days, and the responsible party has not contacted our office to arrange a payment plan, the account will be considered delinquent.
Delinquent accounts will be sent to a collection agency, and we will be required to release all account information to them. At this point:
We will no longer be able to manage the account.
The patient will no longer be eligible for treatment at our office.
Acknowledgment of HIPAA Policy
At Eagle Run West Dental Group, we are committed to protecting your personal health information in compliance with the Health Insurance Portability and Accountability Act (HIPAA). By receiving care at our office, you acknowledge that you have been informed of our HIPAA Privacy Policy, which explains how your health information may be used and disclosed. If you have any questions or need a copy of our HIPAA Privacy Policy, please ask a member of our team.
Assignment of Benefits
I authorize payment directly to the dentist or dental group of my insurance benefits otherwise payable to me. I understand that my dental care insurance carrier or payer of my dental benefits may pay less than the actual bill for services, and that I am financially responsible for payment in full of all accounts. By signing this statement, I revoke all previous agreements to the contrary and agree to be responsible for payment of services not paid by my dental care payoff. I attest to the accuracy of the information on this page.
Patient/Responsible Party Acknowledgment
I acknowledge that I have read and understand the financial policies of Eagle Run West Dental Group. I understand that regardless of my insurance coverage, I am ultimately responsible for all charges incurred for services provided. I agree to pay for any services rendered and any outstanding balances as outlined in this policy. I also understand that failure to make timely payments may result in additional fees, collection actions, and termination of services.
By signing below, I confirm that I have reviewed and agree to the terms of this financial policy.
Signature of Patient or Legal Guardian
–
Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Date
MEDICAL HISTORY
Patient name
Nickname
Date of birth
Dental History
Purpose of initial visit
Are you aware of a problem?
How long since your last dental visit?
What was done at that time?
Previous dentist’s name
Phone
Dentist’s Address
City
State
Zip
Last time teeth cleaned
Were dental x-rays taken?
Yes
No
Are any of your teeth sensitive to:
Hot
Cold
Sweets
Pressure
Do your gums bleed or hurt?
Yes
No
When?
Are you unhappy with the appearance of your teeth?
Yes
No
Please explain
Do you have any questions or concerns?
Yes
No
Please explain
Medical History
Physician’s name
Phone
Physician’s Address
City
State
Zip
Are you under a physician’s care?
Yes
No
Since when?
Why?
When was your last complete physical exam?
Are you taking any medications or substances?
Yes
No
Medication/Substance
Dosage
Frequency
Add another?
Add another?
Add another?
Add another?
Add another?
Add another?
Add another?
Add another?
Add another?
Add another?
Add another?
Do you have any problems with penicillin, antibiotics, anesthetics or other medications?
Yes
No
Please explain
Are you sensitive to any metals or latex?
Yes
No
Are you pregnant or suspect you may be?
Yes
No
Have you ever been treated for or been told you might have heart disease?
Yes
No
Do you have a pacemaker, an artificial heart valve implant, or been diagnosed with mitral valve prolapse?
Yes
No
Have you ever had rheumatic fever?
Yes
No
Are you aware of any heart murmurs?
Yes
No
Do you have high or low blood pressure?
High
Low
Have you ever had a serious illness or major surgery?
Yes
No
Please explain
Have you ever had radiation or chemo treatment?
Yes
No
Please explain
Do you have any artificial joints/prosthesis?
Yes
No
Which joints?
Date
Are you diabetic?
Yes
No
Do you have asthma?
Yes
No
Do you have epilepsy or seizure disorders?
Yes
No
Have you had or do you test positive for hepatitis?
Yes
No
Is there anything else we should know about your health that we have not covered in this form?
Yes
No
Please describe
Would you like to speak to the Doctor privately about any problem?
Yes
No
Please explain
Please list any additional information you feel the Doctors may need to know (medications, surgeries, illnesses, etc.)
Signature of Patient or Legal Guardian
–
Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that the above information is complete and accurate, and that this is a legal representation of my signature.
Date