This form is HIPAA compliant to ensure privacy.

Ralph Costagliola, DDS

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New Patient Registration Form

Patient Information

Title:

Sex:
First Name:

Date of Birth:

Nickname:
Age:
(calculated after submit)
Middle Initial:
Social Security #:
Last Name:
 

 Email:

 
Street Address:
Home Tel. #:
City:
Work Tel. #:
State:
Ext.:
Zip:
Mobile Tel#:
Employer Name:
Occupation:
 
Dentist:
Dentist Phone #:
Referred By:
Physician:
For Doctor:
Physician Phone #:
Spouse Name:
 
Emergency Contact:
Home Tel. #:
 Relation:
Work Tel. #:
 
Marital Status:

Have you ever been a patient of our practice?

How were you referred to our office?



Referral Name :

Method of Personal Payment:

Are you a student? 
 School:
Preferred appointment time:
 

Account Responsibility/Insurance Card Holder

Who will be responsible for your account? (if patient is a minor)
 
Title:

Date of Birth:

First Name:

Social Security #:

Middle Initial:
Driver's License #:
Last Name: Home Tel. #
 

Street Address:

 Mobile Tel. #:

City:

Employer Name:

State:

Emp. Tel. #:

Zip:

(if other) Relation:


Spouse or Guarantor Info (if different from above)

Title:

Social Security #:

First Name:

Tel. #:

Middle Initial:

Mobile Tel#:

Last Name:

Employer Name:

 

Street Address:

Emp. Tel. #:

City:

Relation:

State:

 

Zip:


Primary Dental Insurance

Employer Name:

Group #:

Emp. Tel. #:

Subscriber Name:

Ins. Co. Name:

Subscriber Birthday:

Insurance Tel. #:

SSN/ID/Contract #:

Insurance PO Box:    
Relationship to Patient:

Primary Medical Insurance

Employer Name:

Group #:

Emp. Tel. #:

Subscriber Name:

Ins. Co. Name:

Subscriber Birthday:

Insurance Tel. #:

SSN/ID/Contract #:

Insurance PO Box:    
     Relationship to Patient:

Secondary Insurance

Type of Insurance:

Employer Name:

Group #:

Emp. Tel. #:

Subscriber Name:

Ins. Co. Name:

Subscriber Birthday:

Insurance Tel. #:

SSN/ID/Contract #:

Insurance PO Box:    
     Relationship to Patient:

General Health

Are you in good health?
Has there been any change in your health in the past year?
My last physical exam was on
Are you now under the care of a physician?
If so, for what condition?
The name and address of my physician is:
Have you had any serious illness, operation or hospitalization within the past 5 years?
Have you had an artificial joint replacement (knee, hip, shoulder, etc.)?
Are you taking or have you ever taken Bisphosphonates for osteoporosis or chemotherapy for multiple myeloma or other cancers (Fosamax, Actonel, Boniva, Aredia or Zometa)?
If you take or have taken the above medications, for how long were they taken?
Are you taking any medicine(s) including diet pils, non-prescription, vitamins, homeopathic or natural remedies?
If so, please list:
Do you have or have you had any of the following diseases or problems?
Damaged heart valves, artificial valves or heart murmur
Rheumatic Heart Disease
Heart trouble, heart attack, angina, high blood pressure, stroke, arteriosclerosis or any other heart condition
Chest pain upon exertion?
Shortness of breath after mild exercise?
Do your ankles swell?
Allergies
Sinus trouble
Asthma or hay fever
Fainting spells or seizures
Diabetes
Hepatitis, jaundice or liver disease
Frequent or recurring mouth sores
Thyroid problems
Respiratory problems, emphysema, bronchitis, etc.
Arthritis or painful, swollen joints including jaw joint (TMJ)
Osteoporosis
Stomach ulcer or hyperacidity
Kidney trouble
Tuberculosis
Persistent cough or cough that produces blood
Persistent swollen neck glands
Low blood pressure
Epilepsy or neurological disorder
Cancer
Any disease, drug or transplant operation that has depressed your immune system
Have you had abnormal bleeding?
Have you ever required a blood transfusion?
Do you have any blood disorder such as anemia?
Have you ever had treatment for a tumor or growth?
Have you had radiation therapy to the head, neck or jaws?
Are you allergic to or have you had a reaction to:
Local anesthetics
Penicillin or antibiotics
Sulfa drugs
Barbiturates or sleeping pills
Aspirin
Iodine
Codeine or other narcotics
Latex or rubber products
Other
Have you had any serious trouble associated with previous dental treatment?
If so, explain:
Do you have any other condition or disease you think the doctor should know about?
If so, explain:
Do you smoke or chew Tobacco?
How much?
Is there any past history of alcohol or chemical dependency or emotional disorder that may affect the care we provide you?
Are you wearing contact lenses?
Are you wearing removable dental appliances?
Do you wish to talk with the doctor privately about anything?

Women Only

Are you pregnant or trying to become pregnant?
Do you have problems associated with your menstrual period?
Are you nursing?
Are you taking birth control pills?

Family History (please  check  all  that  apply)







Fees and Payments
We make every effort to keep down the cost of your oral surgical care.  You can help by paying upon completion of each visit.  Other arrangements can be made with our office manager depending upon special circumstances. An estimate of the charge for any procedure or surgery you may require will be given to you upon request. If you have any dental and/or medical insurance we will be glad to fill out the proper forms, but please complete the identifying information on this form.  

Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid for by your insurance company. You will be responsible for all collection costs, attorneys fees, and court costs.


I certify that I have read and understand the above. 
I authorize the release of information necessary to process my claim. I hereby authorize to this doctor named of the benefits otherwise payable to me. 
Patient Acknowledgements
I hereby acknowledge that I have been given the right to review the Notice of Privacy Practices for this office. (HIPAA) A copy of this notice can be viewed here.

I certify that I have read and understand the above.  I affirm that the information contained in this form and any additional information that I may furnish is true and correct to the best of my knowledge.  I understand the above information is necessary to provide me with dental care in a safe and efficient manner.  I will not hold Ralph Costagliola, DDS  or the staff responsible for any errors or omissions that I have made in the completion of this form.

  
  Signature                                                                                                                 Date        

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