Patient Registration Form
Thank you for choosing our practice! We look forward to taking care of all your dental needs. Please fill out this form in ink only. If you have any questions regarding this form do not hesitate to ask for assistance. We will be happy to help.
Patient Name: __________________________________________________ Date: ________________ Birthdate: ________________ (Last, Middle, First )
SS#: ________________________________ DL#: _________________________ SEX: Male Female
Marital Status: Single Married Divorced Widowed Partnered Spouse’s Name: _________________________________________
Home Phone: ___________________________ Cell Phone:____________________________ Pager:___________________________
Email Address:______________________________________________________ Work Phone:_______________________________
What is the best way to contact you? Home Cell Pager Email Work Mail
Employer/School Name:__________________________________________ Occupation:______________________________________
Who may we thank for referring you?_________________________________________________
Name of person responsible for account:___________________________________________ Relationship:_______________________
Birthdate:___________________________ Age:____________ SS#:_________________________ Phone:______________________
Address:___________________ __________________________________ City/State/Zip:_____________________________________
Employer Name:___________________________________________________ Work Phone: ________________________________
*Please list an Emergency Contact not living with you (Name/Phone):______________________________________________________
PRIMARY DENTAL INSURANCE INFORMATION
Subscriber’s Name:_____________________________________________________ Relationship:____________________________
Birthdate:___________________ SS#:_________________________________ ID#:_______________________________________
Insurance Company:_________________________________________________ Group #:___________________________________
Insurance Phone#:______________________________ Insurance Address:_______________________________________________
Employer’s Name:_______________________________________________ Work Phone: ___________________________________
SECONDARY DENTAL INSURANCE INFORMATION
Do you have secondary dental insurance? YES NO
Subscriber’s Name: ___________________________________________________ Relationship: ______________________________
Birthdate: ___________________ SS#: __________________________________ ID#: ______________________________________
Insurance Company: _________________________________________________ Group #: ___________________________________
Insurance Phone: ____________________________ Insurance Address: __________________________________________________
Employer’s Name: __________________________________________________ Work Phone: _________________________________
Former Dentist:____________________________________________ City:____________________________ State:________________
Phone:________________________________________ May we contact them? YES NO
Why did you leave your previous dental office?_________________________________________________________________________
What is the most important reason for your dental visit today?_____________________________________________________________
The most important thing about your future smile and dental health is:_______________________________________________________
On a Scale of 1-10, with 10 being the highest rating:
Your Last Cleaning:______________________
Your Last set of X-rays:___________________
Your Last Oral Cancer Screening:___________
Where would you rate your current dental health?
Your Last Dental Exam:___________________
Where do you want your dental health to be?
Do any of the following problems apply to you?
Jaw Joint Pain, Grinding, Clenching YES NO
Bleeding, Swollen or Irritated Gums YES NO
Do you have/had any of the following? Dentures Partials Braces Periodontal (gum) Treatment
Physician’s Name:_______________________________________ Phone:_______________________ Last Exam:________________
Have you been hospitalized within the last 5 years? YES NO If yes, reason: ____________________________________________
For the following please circle yes or no. Your answers are for our records only and will be confidential. Please note that during your initial visit you will be asked some questions about your responses. Our staff may ask additional questions regarding your health.
Arthritis, Rheumatism or Inflammatory Disease
Emphysema or other Respiratory/ Lung Illness
Heart Valve (artificial) or Heart Transplant
Heart Disease, Heart Attack, Heart Surgery
Name: ______________________________________________________ Age: ________________ Date: _______________________
Are you taking any of these medications?
Do you Pre-Medicate before dental visits?
Tagamet (Cimetidine) or Prilosec (Omeprazole)
Cardizem (Diltiazem) or Calan, Isoptin (Verapamil)
Diflucan (Fluconazole) or Sporonox (Itraconazole)
Do you consume grapefruits, juice, or extract
Have you been treated with bisphoshonate drugs (Fosamax, Aredia, Zometa, Actonel, Boniva)? YES NO
If so, when did the treatment start: ______________________________
Please list any medications or dietary/herbal supplements you are currently taking and for what purpose:
1. _________________________________________ 2. _________________________________________
3. _________________________________________ 4. _________________________________________
5. _________________________________________ 6. _________________________________________
Are you allergic or have reactions to:
If yes, approximately how many per week? ________
Do you use any mood altering drugs other than those previously listed? YES NO
Certification and Assignment
To the best of my knowledge the above information is complete and correct. I understand that the above information is necessary to provide me with dental care in a safe and efficient manner. I understand that it is my responsibility to inform the doctor if I, or my minor child, ever have a change in health. Should further information be needed you have my permission to ask the respective health care provider or agency, who may release such information to you. I certify that I and my dependant(s), have insurance coverage with ___________________________________and assign directly to Mason Dental and Dr. Michael Mason all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance claims. The above-named doctor and facility may use my health care information and may disclose such information to the above-named insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. I hearby authorize Mason Dental to take study models, X-rays, and any other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of the patient’s dental needs. I also authorize Mason Dental to perform any and all forms of treatment, medication, and therapy that may be indicated, I also understand that the use of anesthetic agents embodies a certain risk.
By signing below you are stating you understand the following: Payment is due at the time services are rendered. Our office accepts cash, personal checks, MasterCard, Visa, and Discover. Our office also offers outside financing upon request and approval please ask for further details. I authorize this office to obtain a copy of my credit report from a credit reporting agency for the purpose of considering payment options. As a courtesy to our insured patients, we will gladly file your dental claims for services rendered, with the exception of those patients currently carrying Delta Dental Insurance. Delta Dental prefers to remit payment to the patient instead of the providing doctor. For this reason, patients with Delta Dental are required to remit payment to us at the time of service and be reimbursed by their insurance. Please understand that we are only given an estimate for your dental care therefore we can only pass the estimate on to you, the patient. After your insurance pays their portion there may still be an amount due. This amount will be your responsibility and will be sent to you in the form of a statement. We will do our best to get your insurance to pay for all work performed by our office, however most insurance plans only pay for a portion of dental services. Please understand that if after 60 days there has been no payment made, it is your responsibility to follow up with your insurance and retain payment.
Patient, Parent, Guardian, or Personal Representative
Doctor’s Signature:_______________________________________________________________ Date:________________________
HIPAA Consent Form
I understand that I have certain rights to privacy regarding my protected health information (PHI). These rights have been given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent form, I authorize Mason Dental to use and disclose my protected health information to carry out:
• Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment) • Obtaining payment from third party payers (e.g. insurance company) • Day-to-day healthcare operations of the practice (email/ text reminders/ confirmations of appointments
I have also been informed of, and given the right to review a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that Mason Dental reserves the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.
I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and healthcare operations, but that you are not required to agree to these restrictions. However, if you do agree, you are then bound to comply with these restrictions.
I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.
Signed this _______________ day of ________________, 20_____.
Michael Mason, DDS
99 Rosemar Road, Parkersburg, West Virginia 26104
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