St. Anthony Park Dental Care

Patient Registration Form

Patient Sign-in
New patient Registration
Medical History
Medical history

Patient Registration( * mandatory to fill )

  Email    Text Message (Cell #)    Phone

Who do we contact in case of an emergency?( * mandatory to fill )

Please select below

Is the Patient Responsible for the Account?
Yes No
Do You Have Primary Dental Insurance?
Yes No
Do You Have Secondary Dental Insurance?
Yes No
I have read the above choices

Primary Dental Insurance( * mandatory to fill )

SIGNATURE
 
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(Your IP Address : )

Secondary Dental Insurance( * mandatory to fill )

SIGNATURE
 
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(Your IP Address : )

Responsible Person for the Account( * mandatory to fill )

Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

(All questions are required * )

Are you under a physician's care now?
Yes
No
Have you ever been hospitalized or had a major operation?
Yes
No
Have you ever had a serious head or neck injury?
Yes
No
Are you taking any medication, pills or drugs?
Yes
No
Do you take, or have you taken, Phen-fen or Redux?
Yes
No
Are you on a special diet?
Yes
No
Do you use tobacco?
Yes
No
Do you use controlled substances?
Yes
No
I have answered all the above questions

Medical History

Are you a woman?
Yes
No
Are you pregnant/trying to get pregnant?
Yes
No
Are you taking oral contraceptives?
Yes
No
Are you Nursing
Yes
No
Are you allergic to any of the following?
I have answered all the above questions

Medical History

Do you have, or have you had, any of the following?

AIDS/HIV Positive
Yes
No
Alzheimers disease
Yes
No
Anaphylaxis
Yes
No
Anemia
Yes
No
Angina
Yes
No
Arthritis/Gout
Yes
No
Artificial Heart Valves
Yes
No
Artificial Bones/Joints
Yes
No
Asthma
Yes
No
Blood Disease
Yes
No
Blood Transfusion
Yes
No
Breathing Problems
Yes
No
Bruise Easily
Yes
No
Cancer
Yes
No
Chemotherapy
Yes
No
Chest Pain
Yes
No
Cold sores / Fever blisters
Yes
No
Congenital heart disorder
Yes
No
Convulsion
Yes
No
Cortisone medicine
Yes
No
Diabetes
Yes
No
Difficulty Breathing
Yes
No
Drug Addiction
Yes
No
Easily Winded
Yes
No
Emphysema
Yes
No
Epilepsy or Seizures
Yes
No
Excessive Bleeding
Yes
No
Excessive Thirst
Yes
No
Fainting spells / Dizziness
Yes
No
Frequent Cough
Yes
No
Frequent Diarrhea
Yes
No
Frequent Headaches
Yes
No
Genital Herpes
Yes
No
Glaucoma
Yes
No
Hay Fever
Yes
No
Heart Attack / Failure
Yes
No
Heart Murmur
Yes
No
Heart Pacemaker
Yes
No
Heart Trouble / Desease
Yes
No
Hemophilea
Yes
No
Hepatitis A
Yes
No
Hepatitis B or C
Yes
No
Herpes
Yes
No
High Blood Pressure
Yes
No
Hives or Rash
Yes
No
Hypoglycemia
Yes
No
Irregular Heartbeat
Yes
No
Kidney Problem
Yes
No
Leukemia
Yes
No
Liver Disease
Yes
No
Low Blood Pressure
Yes
No
Lung diseases
Yes
No
Mitral Valve prolapse
Yes
No
Osteoporosis
Yes
No
Pain in Jaw Joints
Yes
No
Parathyroid Disease
Yes
No
Psychiatric Care
Yes
No
Radiation Treatments
Yes
No
Recent Weight Loss
Yes
No
Renal Dialysis
Yes
No
Rheumatic Fever
Yes
No
Rheumatism
Yes
No
Scarlet Fever
Yes
No
Shingles
Yes
No
Sickle Cell Disease
Yes
No
Sinus Trouble
Yes
No
Spina Bifida
Yes
No
Stomach/Intestinal Disease
Yes
No
Stroke
Yes
No
Swelling of Limbs
Yes
No
Thyroid Disease
Yes
No
Tonsillitis
Yes
No
Tuberculosis
Yes
No
Tumors or Growths
Yes
No
Ulcers
Yes
No
Venereal Disease
Yes
No
Yellow Jaundice
Yes
No
Have you ever had serious illnesses not listed?
Yes
No
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my(or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.
SIGNATURE
 
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(Your IP Address : )

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I, , have received a copy of this office's Notice of Privacy Practices.

SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

FINANCIAL OPTIONS

Thank you for choosing our office for your dental needs. We realize that every person's financial situation is different. For this reason, we have worked hard to provide a variety of payment options to help you receive the dental care you need and deserve. These options will allow you to enjoy a healthy, beautiful smile while respecting your budget. Dental treatment is an excellent investment in an individual's medical and psychological well-being. Financial considerations should not be an obstacle to obtaining this important, life-enhancing care. We are always available to answer your questions or assist you in any way.

For our patients with dental insurance, we, are happy to submit your insurance claim for services provided. Please be aware that some insurance companies pay a fixed allowance for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, coinsurance, or any other balance left unpaid by your insurance company. This ESTIMATED portion is due at or prior to your initial appointment. If the particular procedure requires several appointments, we will expect half the payment at the initial appointment with full payment by the last.

For your convenience, we provide the following payment options:

  • 1. Cash or check: 5 % courtesy allowance (for same day payment from patients without insurance).
  • 2. Major credit cards: Visa, Mastercard, American Express, or Discover.
  • 3. Heath Care Credit Line (No interest payment plan): Care Credit (apply at WWW.CareCredit.Com).

I, , prefer to have my ESTIMATED portion or balance paid by:

Cash or check
Major credit card
Health Care Credit Line
HSA
SIGNATURE
 
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(Your IP Address : )

St. Anthony Park Dental Care

Thank you for visiting St. Anthony Park Dental Care. We want your visit to be pleasant and comfortable. Please help us by completing this form
Patient Information

Personal Details

Title:           First Name:           Last Name:           Middle Initial:          
Preferred Name:           Birth Date:           Gender:           Marital Status:          
Address:           City:           State:           Zip Code:          
Email Text Message (Cell #) Phone

Who do we contact in case of an emergency?

Email Address:          
Home Phone:           Work Phone:           Cell Phone:          
Patient Employed by:           Occupation:           Whom may we thank for referring you?:          

Primary Dental Insurance

Policy Holder Name: SS # or Alternate ID: Birth Date: Employer's Name:
Insurance Company: Group #:
Claims' Address: City: State: Zip Code:
Insurance Company Phone Number: Relationship to employee:
Do You have Primary Dental Insurance? Yes No

Secondary Dental Insurance

Policy Holder Name: SS# or Alternate ID: Birth Date: Employer's Name:
Insurance Company: Group #:
Claims' Address: City: State: Zip Code:
Insurance Company Phone Number: Relationship to Employee:
Do You have Secondary Dental Insurance? Yes No

Responsible Person for the Account

Person Responsible for Account: Responsible person's address: Emergency Contact Name: Phone Number:
Medical History
Are you under a physician's care now?
Yes
No
If yes, please explain:
Have you ever been hospitalized or had a major operation?
Yes
No
If yes, please explain:
Have you ever had a serious head or neck injury?
Yes
No
If yes, please explain:
Are you taking any medication, pills or drugs?
Yes
No
If yes, please explain:
Do you take, or have you taken, Phen-fen or Redux?
Yes
No
Are you on a special diet?
Yes
No
Do you use tobacco?
Yes
No
Do you use controlled substances?
Yes
No
Are you a woman?
Yes
No
Are you allergic to any of the following?
Aspirin Penicillin Codeine Acrylic
Metals Latex Local anesthetics Other
If Other, Please Specify:
Do you have, or have you had, any of the following ?
AIDS/HIV Positive Alzheimer's disease Anaphylaxis
Anemia Angina Arthritis/Gout
Artificial Heart Valves Artificial Joint Asthma
Blood Disease Blood Transfusion Breathing Problems
Bruise Easily Cancer Chemotherapy
Chest Pain Cold sores / Fever blisters Congenital heart disorder
Convulsion Cortisone medicine Diabetes
Difficulty Breathing Drug Addiction Easily Winded
Emphysema Epilepsy or Seizures Excessive Bleeding
Excessive Thirst Fainting spells / Dizziness Frequent Cough
Frequent Diarrhea Frequent Headaches Genital Herpes
Glaucoma Hay Fever Heart Attack / Failure
Heart Murmur Heart Pacemaker Heart Trouble / Desease
Hemophilea Hepatitis A Hepatitis B or C
Herpes High Blood Pressure Hives or Rash
Hypoglycemia Irregular Heartbeat Kidney Problem
Leukemia Liver Disease Low Blood Pressure
Lung diseases Mitral Valve prolapse Osteoporosis
Pain in Jaw Joints Parathyroid Disease Psychiatric Care
Radiation Treatments Recent Weight Loss Renal Dialysis
Rheumatic Fever Rheumatism Scarlet Fever
Shingles Sickle Cell Disease Sinus Trouble
Spina Bifida Stomach/Intestinal Disease Stroke
Swelling of Limbs Thyroid Disease Tonsillitis
Tuberculosis Tumors or Growths Ulcers
Venereal Disease Yellow Jaundice
Have you ever had any serious illnesses not listed above?
Yes
No
If yes, please explain:
Comments:
 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I, , have received a copy of this office's Notice of Privacy Practices.

Name:
 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

FINANCIAL OPTIONS

Thank you for choosing our office for your dental needs. We realize that every person's financial situation is different. For this reason, we have worked hard to provide a variety of payment options to help you receive the dental care you need and deserve. These options will allow you to enjoy a healthy, beautiful smile while respecting your budget. Dental treatment is an excellent investment in an individual's medical and psychological well-being. Financial considerations should not be an obstacle to obtaining this important, life-enhancing care. We are always available to answer your questions or assist you in any way.

For our patients with dental insurance, we, are happy to submit your insurance claim for services provided. Please be aware that some insurance companies pay a fixed allowance for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, coinsurance, or any other balance left unpaid by your insurance company. This ESTIMATED portion is due at or prior to your initial appointment. If the particular procedure requires several appointments, we will expect half the payment at the initial appointment with full payment by the last.

For your convenience, we provide the following payment options:

  • 1. Cash or check: 5 % courtesy allowance (for same day payment from patients without insurance).
  • 2. Major credit cards: Visa, Mastercard, American Express, or Discover.
  • 3. Heath Care Credit Line (No interest payment plan): Care Credit (apply at WWW.CareCredit.Com).

I, , prefer to have my ESTIMATED portion or balance paid by:

Cash or check
Major credit card
Health Care Credit Line
HSA
 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

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