Patient Registration Date: First Name Last Name Middle Initial Preferred Name E-mail Patient Information Address City State Zip Home Phone Cell Phone Work Phone Ext Birthdate Age Social Security Drivers License Sex Marital Status Employer Responsible Party (if someone other than the patient) First Name Last Name Middle Initial Address City State Zip Home Phone Cell Phone Work Phone Ext Birthdate Age Social Security Drivers License In Case of Emergency Contact Name Relationship Home Phone Cell Phone Work Phone Ext Primary Insurance Information Name of Insured Relationship Insured Social Security Insured Birth Date Insured ID # (usually found on dental insurance card) Employer Insurance Company Group # Phone # Address
Medical History Although dental personnel primarily treat the area in and around your mouth, your mouth is 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. Are you under a physician s care now? Y / N If yes explain Have you ever been hospitalized? Y / N Have you ever had a serious neck injury? Y / N Are you taking any medications, pills or drugs? Y / N Are you on a special diet? Y / N Do you use controlled substances? Y / N Women: Are you pregnant/trying to get pregnant? Taking Oral contraceptives? Nursing? Are you allergic to any of the following? Aspirin Penicillin Codeine Acrylic Metal Latex Local Anesthetic Other: Do you have, or have you had any of the following? AIDS/HIV Positive Y / N Cortizone Medicine Y / N Hemophelia Y / N Renal Dialysis Y / N Alzheimer's Disease Y / N Diabetes Y / N Hepatitis A Y / N Rheumatic Fever Y / N Anaphylaxis Y / N Drug Addiction Y / N Hepatitis B or C Y / N Rheumatism Y / N Anemia Y / N Easily Winded Y / N Herpes (mouth) Y / N Scarlet Fever Y / N Angina Y / N Emphysema Y / N High Blood Pressure Y / N Shingles Y / N Arthritis/ Gout Y / N Epilepsy or Seizures Y / N Hives or Rash Y / N Sickle Cell Anemia Y / N Artificial Joint Y / N Excessive Bleeding Y / N Hypoglycemia Y / N Sinus Trouble Y / N Asthma Y / N Excessive Thirst Y / N Irregular Heartbeat Y / N Spina Bifida Y / N Artificial Heart Valve Y / N Fainting Spells Y / N Kidney Problems Y / N Stomach/Intestinal Disease Y / N Blood Disease Y / N Frequent Coughs Y / N Leukemia Y / N Stroke Y / N Blood Transfusion Y / N Frequent Diarrhea Y / N Liver Disease Y / N Swelling of Limbs Y / N Breathing Problems Y / N Frequent Headaches Y / N Low Blood Pressure Y / N Thyroid Disease Y / N Bruise Easily Y / N Genital Herpes Y / N Lung Disease Y / N Tonsilitis Y / N Cancer Y / N Glaucoma Y / N Mitral Valve Prolapse Y / N Tuberculosis Y / N Chemotherapy Y / N Hay Fever Y / N Pain in Jaw Joints Y / N Tumors or Growths Y / N Chest Pains Y / N Heart Attack / Failure Y / N Parathyroid Disease Y / N Ulcers Y / N Cold Sores/Fever Blisters Y / N Heart Murmur Y / N Psychiatric Care Y / N Venereal Disease Y / N Congenital Heart Disorder Y / N Heart Pace Maker Y / N Radiation Treatments Y / N Yellow Jaundice Y / N Convulsions Y / N Heart Trouble /Disease Y / N Recent Weight Loss Y / N Sleep Apnea/Snoring Y / N Have you ever had any serious illness not listed above? If yes, please explain: Do you have any trouble sleeping or are you chronically tired throughout the day? If yes, please explain:
Dental History Reason for today s visit: Are you in pain? Do you smoke/chew tobacco? If yes, how long? Former Dentist City/State Date of Last visit Date of Last X-rays Whom may we thank for referring you? Who is your favorite Musician/ Band? Are you happy with your teeth s appearance? Are you happy with the function of your teeth? Is there anything you would change about your teeth? Have you ever had a bad dental experience? If yes, please describe: Do you have, or have you ever had any of the following? Bad Breath Y / N Bleeding Gums Y / N Blisters on/around Mouth Y / N Burning Sensation on Tongue Y / N Cigarette, Cigar Smoking Y / N Chew on one side of mouth Y / N Dry Mouth Y / N Fingernail Biting Y / N Foreign Objects Y / N Lip or Cheek Biting Y / N Loose Teeth Y / N Broken Fillings Y / N Mouth Breathing Y / N Mouth Pain, Brushing Y / N Orthodontic Treatment Y / N Pain Around Ear Y / N Periodontal Treatment Y / N Sores/Growths in Mouth Y / N If answering Yes to any of the following please explain: Food Collection Between Teeth Y / N Grinding Teeth Y / N Gums Swollen or Tender Y / N Jaw Pain or Tiredness Y / N Sensitivity to Heat Y / N Sensitivity to Cold Y / N Sensitivity to Sweets Y / N Sensitivity when Biting Y / N How often do you floss? How often do you brush? 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 of Patient, Parent or Guardian Date
Authorization and Consent Form Patient Name Date of Birth Date of Visit Our notice of Privacy Practices provides information about how we may use and disclose protected health information about you. You have the right to review our notice before signing this consent. A copy of the Notice of Privacy Practices accompanies this consent at your request. You have the right to request that we restrict how protected health and dental information about you is used or disclosed for treatment, payment, or dental care operations. We are not required to agree to this restriction, but if we do, we are bound by our agreement. By signing this form, you consent to our use and disclosure of protected health and dental information about you for treatment, payment and health care operations. Your information will be disclosed to your insurance company for billing purposes. You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your consent. In the event a family member or caregiver attends my office visit and remains in the operatory at the time of my evaluation and/or treatment, I give Dr. Spear, or his employees, my permission to discuss freely my condition, treatment or diagnosis. May we mail dental related information to your home? Yes / No Any and all dental information can be released to the following: 1. Relationship 2. Relationship 3. Relationship Assignment of Benefits: I hereby authorize all insurance companies to pay directly to Brent Spear, D.D.S. I understand that this order does not relieve me of my obligation to pay the account. Also, any balance that is not covered or paid by the insurance company is my responsibility. Patient/Guardian Signature: Date Financial Responsibility Agreement INSURANCE: I understand and agree that I will be financially responsible for any and all charges for services not paid by my insurance for my visits. This includes any dental service or visit, examinations, x-rays, treatment or any other service performed by the dentist or the dentist s staff. I understand and agree it is my responsibility and not the responsibility of the dentist or dentist s staff to know if my insurance will pay for my dental service or visit. I understand and agree it is my responsibility to know if my insurance has any deductible, co-payment, and out-of-network amount. I understand and agree it is my responsibility to know if the dentist is a contracted in-network provider recognized by my insurance company or plan. If the dentist I am seeing is not recognized by my insurance company or plan, it may result in claims being denied or higher out of pocket expense to me. I understand this and agree to be financially responsible and make full payment. NO INSURANCE: I understand and agree that I will be financially responsible for any and all charges for dental services performed by the dentist or her staff. I understand and agree it is my responsibility to pay for all dental charges at the time of service. I understand and agree that it is not the policy of the office of Brent Spear, D.D.S. to offer payment plans for any dental services. I understand and agree in the event that my account is turned over to a collection agency, I will be held accountable for any and all service fees incurred. Patient/Guardian Signature: Patient/ Guardian Name Printed: Date Date
We would like to give you a new and simpler way to be reminded about your appointments. Our office is introducing a patient login portal that offers you the convenience of 24/7 access to your account information as well as the ability to choose how you would prefer to be contacted by us. If you choose the email option, you will be sent log in information via email. The log in can be accessed on our website: www.brentspeardental.com Please let us help you get started! How would you like to be notified for your appointments? (Please check appropriate space and provide email address or number as needed after the options.) Email Text message (cell) Phone call Appointments and Cancellations When we make your appointment, we are reserving a room for your particular needs. We ask that if you must change an appointment, please give us at least 24 hours notice. This courtesy makes it possible to give your reserved room to another patient who would like it. There is a charge for not showing up for scheduled appointments. Repeated cancellations or missed appointments will result in loss of future appointment privileges. We feel that our patient's time is valuable. When your appointment is made, a room is reserved, your records are prepared, and special instruments are readied for your visit. Except for emergency treatment for another patient, you can expect us to be prompt. We, of course, would appreciate the same courtesy from you. By signing, you acknowledge and agree to the above appointment cancellation policy. Signature of Patient Date