Adult Registration Form

Confidential Patient Medical History

First Name* Middle Initial Last Name* Nickname Date*
Address* Apt# Date of Birth*
City* State* Zip* Code Social Security Number
Home Phone* Work Phone Cell Phone Marital Status
Sex*
Home Phone 2 Work Phone 2 Cell Phone 2 Spouse’s Name
Physician Name Address Physician Phone Employer / college
Pharmacy Name Address Pharmacy Phone Your Email Address*
Name and Address of emergency contact (other than your family home)*
Phone*
How did you hear about us?
Other family members seen here:

If female, please answer the following:

Are you taking birth control?
What kind?
Are you pregnant or trying to get pregnant?
If yes, how many weeks along?
Are you nursing?
Height Weight BP Heart Rate
Tobacco use?
How much do you use?
Abnormal Bleeding Frequent Headaches Sickle Cell Disease
Alcohol Abuse History YN Glaucoma YN Sinus Problems YN
Allergies YN Hay Fever YN Sleep Apnea (Snoring) YN
Anemia (Low Iron) YN Heart Attack YN Stroke YN
Angina (Chest Pain) YN Heart Surgery YN Thyroid Problems YN
Arthritis YN Hemophilia YN Tuberculosis YN
Artificial Joints YN Hepatitis A YN Ulcers YN
Artificial Heart Valve YN Hepatitis B YN Venereal Disease YN
Asthma YN High Blood Pressure YN Yellow Jaundice YN
Blood Transfusion YN HIV or AIDS YN Cancer / Chemotherapy YN
Kidney Problems YN Colitis (Irritable Bowel) YN Liver Disease or Hepatitis C YN
Congenital Heart Defect YN Low Blood Pressure YN Cosmetic Surgery YN
Mitral Valve Prolapse YN Diabetes YN Pace Maker YN
Drug Abuse History YN Psychiatric Problems YN Emphysema YN
Radiation YN Epilepsy YN Rheumatic Fever YN
Fainting Spells YN Seizures YN Fever Blisters YN
Shingles YN

ALLERGIES

Aspirin YN Codeine YN Dental Anesthetics YN
Erythromycin YN Jewelry YN Latex YN
Metals YN Penicillin YN Tetracycline YN
Other

Medications

Check this box if you are NOT taking any type of medications Not on medication

Is there any disease, condition or problem that you think this office should know about that is not covered above? If yes, please describe below. YN

Bisphosphonates Informed Consent

Any dental procedures performed including but not limited to extractions, Endodontics, orthodontics, and any surgical procedure may cause bone and/or infection complications including but not limited to bone necrosis as a result of these medications.

Please check if you have taken or been treated with the following drugs for osteoporosis or metastatic bone cancer:

Etidronate (Didronel) YN Bonefos YN
Alendronate (Fosamax) YN Fosamax Plus D YN
Pamidronate (Aredia) YN Skelid YN
Ibandronate (Boniva) YN Zoledronic Acid (Zometa) YN
Riseddronate (Actonel) YN Fosamax (Alendronate Sodium) YN
Boniva (Ibandronate Sodium) YN Actonel (Risidronate) YN
Pamidronate IV YN Zolendronate IV YN
I have been treated for metastatic bone cancer. YN

HIPAA OMNIBUS RULE PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND CONSENT/ LIMITED AUTHORIZATION & RELEASE FORM

You may refuse to sign this acknowledgement & authorization. In refusing we may not be allowed to process your insurance claims.

Date: [ today's date ]

The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for Lifetime Dental Care. A copy of this signed, dated document shall be as effective as the original.

MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR / FACILITIES IN THE FUTURE.

Please print name of Patient Please sign for Patient / Guardian of Patient
Legal Representative / Guardian Relationship of Legal Representative / Guardian
Your comments regarding Acknowledgements or Consents:

HOW DO YOU WANT TO BE ADDRESSED WHEN SUMMONED FROM THE RECEPTION AREA: First Name OnlyProper SurnameOther

PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION: (This includes step parents, grandparents and any care takers who can have access to this patient’s records):

Name Relationship
Name Relationship

I AUTHORIZE CONTACT FROM THIS OFFICE TO CONFIRM MY APPOINTMENTS, TREATMENT & BILLING INFORMATION VIA:

I AUTHORIZE INFORMATION ABOUT MY HEALTH BE CONVEYED VIA:

I APPROVE BEING CONTACTED ABOUT SPECIAL SERVICES, EVENTS, FUND RAISING EFFORTS or NEW HEALTH INFO on behalf of this Healthcare Facility via:

In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or services to promote your improved health. This office may or may not receive third party remuneration from these affiliated companies. We, under current HIPAA Omnibus Rule, provide you this information with your knowledge and consent.

Office Use Only

As Privacy Officer, I attempted to obtain the patient’s (or representatives) signature on this Acknowledgement but did not because:

    It was emergency treatment
    I could not communicate with the patient
    The patient refused to sign
    The patient was unable to sign because
Other (please describe)
   


    Signature of Privacy Officer

PATIENT FINANCIAL POLICY

  1. For those with insurance benefits, we are happy to bill your insurance as a courtesy to you. Please note that your =insurance contract exists solely between you and your insurance carrier. We will file your insurance claim, but we cannot guarantee any benefits. Your insurance plan is a benefit to you to help offset the cost of necessary dental care. Ultimately, you are responsible for the entire cost of your dental treatment. In some cases, if you do have insurance coverage, we may still ask you to pay in full on the date of service. Any questions or comments regarding your benefits should be directed to your insurance carrier. If the balance is not cleared within 60 days, you will be charged a billing fee of $5.00 monthly.
  2. Payment at the time of service is expected, or the estimated portion of the amount that insurance does not cover. Our office accepts the following credit cards: MasterCard, VISA, American Express, Discover and Care Credit. There is a prepay 10% reduction in fees for your next appointment when you make the appointment if paid in full with cash or check at the time of scheduling treatment. Sedation appointments, “Invisalign”, and credit card payments are excluded from the 10% offer. Also excluded are patients with PPO contracts due to the contractual discounts in their policies. (Sedation appointments require pre-payment, Invisalign requires $610.00 non-refundable deposit before sending out case. Some of the Invisalign fee may or may not be reimbursed by your insurance depending upon your policy parameters.)
  3. When the patient’s portion cannot be paid at the time of service and payment arrangements extend beyond 60 days, a billing fee of $5.00 per month will be charged on all outstanding balances regardless of estimated insurance.
  4. A credit qualification will be researched on each new patient before being offered payment arrangements.
  5. A statement for services rendered will be mailed to you every four weeks. Receipt of payment is expected within 21 days of the postmark. The patient’s payment should be mailed with the top portion of the statement to establish the proper crediting of the account.
  6. Your account due is considered delinquent if the requested payment is not received 21 days after billing. If payment is not received, a billing fee of $5.00 per month will be assessed after 60 days, and will appear on the next statement. All fees are subject to change without a new form’s being signed.
  7. A $35.00 charge will be billed to your account for any check returned by the bank for any reason. We will resubmit the check for payment to the bank one time. However, if funds are still insufficient, we will not accept payments by check from you in the future.
  8. There will be no charge for a broken appointment with 24 hours’ notice. This enables us to fill the reserved time slot from our list of patients who are able to come on short notice. Broken appointments with less than 24 hours’ notice will incur a fee of $45.
  9. Before records can be transferred, you must sign a privacy release form and pay the $28.00 x-ray duplicating fee if needed.
  10. Delinquent accounts after 90 days may be sent to a collection agency or small claims court. Any fees incurred for the collection of a debt are the responsibility of the patient or guarantor and will be added to the account.
I have read and understand the financial policy of Dr. Tony Butchert and agree to all the terms described in it.
Patient Signature/Guardian Signature     Date
If signed by Guardian, please print patient’s name above.

Patient Dental Questionnaire

What is your main dental concern?

How many years since your last dental exam?

Since your last dental x-rays?

Please select your biggest reasons for avoiding the dentist.

Does tooth discomfort wake you at night? YN

Are you taking pain pills for any discomfort? YN

If yes, what are you taking?
Are they working? YN

Are your teeth sensitive to...?

Do you have a bad taste or bad breath? YN

How often do you floss?

How often do you brush?

Brush Type:

Do your gums bleed, do you see pink after brushing?

If you could have it any way, how many more years would you like to have your teeth?

Would you like a 5 year warranty on any procedure for an extra 10% premium?

Have you had braces or retainers?

Would you like whiter teeth?

Would you like straighter teeth?

Would you like your smile to look different?

How many cups of coffee a day do you drink?

With cream? Sugar?

How many cans of soda? Brand

Do you chew gum daily?

Does your jaw snap, click, or pop?

Do you clench your teeth?

Has anyone heard you snoring at night?

Do you get headaches weekly?

Have you ever awakened with a headache?

Do you use tobacco products?

Do you sweat or tremble during examination?

Do strange people or places make you afraid?

Do you consider yourself a touchy person?

Are you unhappy or depressed?

Are you easily upset or irritated?

How did you choose this office?


On a scale of 1 - 10 with 10 the highest rating, please choose one.

How important is your dental health to you?
Where would you rate your current dental health?
Where would you like to see your dental health 5 - 10 years from now?
What do you perceive your insurance benefits to pay? (1) Nothing At All, (10) Pays Everything
Patient / Guardian Signature Print Patient Name     Date

Dental Benefits Processing Information

Dental benefit coverage available?

Is there a second dental insurance policy?

The information requested is the minimum required for accurate and efficient billing and processing of your insurance. We will not be able to bill insurance claims without this data.

AUTHORIZATION TO BILL / PROCESS INSURANCE

I hereby authorize my insurance benefits be paid directly to the dentist. I authorize the release of any information required by my insurance company to facilitate the processing of all claims. I authorize that my records can be used by the doctor if he so determines. In consideration of the services rendered to me by this dental office, I am obligated to pay said office in accordance with its credit terms and policy. I understand that I am financially responsible for any balances after 60 (sixty) days whether or not my insurance has settled. Any fees associated with the collection of unpaid balances are the responsibility of the guarantor / subscriber. I certify that I have read or had read to me, if requested, the contents of this form and do realize the risks and limitations of receiving timely insurance reimbursement. I understant that with out the above requested infomation, insurance con not be processed.

Patient Signature/Guardian Signature     Date

 

 

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NEW PATIENT EXCLUSIVE OFFER!

Free Exam, Cavity Detection & 3-D x-ray*

*With Insurance: Cleaning, exam and all x-rays are covered.

*No Insurance: With a paid Cleaning ($88), a complete exam, cavity detection x-rays, and panoramic x-ray are all included.



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Free Exam, Cavity Detection & 3-D x-ray*

*With Insurance: Cleaning, exam and all x-rays are covered.

*No Insurance: With a paid Cleaning ($88), a complete exam, cavity detection x-rays, and panoramic x-ray are all included.





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