This form is HIPAA compliant to ensure privacy.

Dr. Leonard J. Goldman, D.D.S.

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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:
 

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:

General Health

Are you under the care of a physician?
Date of last visit:
For what are you being treated?
Have you had any illness, operation or been hospitalized in the past five years?
Do you have a heart valve replacement, history of endocarditis or an artificial joint?
Where/What Year:
Do you need to take antibiotics prior to having dental care?
Are there conditions that the doctor should be aware of?
Do you wish to speak to the doctor privately regarding your conditions?

Conditions

High / Low blood pressureChest pain / angina
Heart Murmur / Mitral Valve ProlapseIrregular heartbeat
Cardiac pacemakerHeart surgery
Artificial heart valveStroke
Heart attack(s)Blood transfusion
Swollen ankles, arthritis, or joint diseaseChronic fatigue / night sweats
Rheumatic feverDamaged heart valves
Problems with the immune systemSexually transmitted diseases
Tumor or growthX-Ray treatment / chemotherapy
ArthritisSteroid medication (prednisone)
Malignant hyperthermiaHIV/AIDS
I smokeDifficult breathing / other lung trouble
Bronchitis / chronic cough / emphysemaAsthma
Hay fever / sinus problemsTuberculosis
I take blood thinner medicationThyroid trouble
Low blood sugarDiabetes
Stomach ulcersGallbladder trouble
Blood disorder such as anemiaSickle cell disease
Bruise easilyBleeding tendency (abnormal bleeding)
Mental health problemsHistory of drug / alcohol abuse
Convulsions / epilepsyFainting spells
Kidney trouble / DialysisEye Disease / Glaucoma
Liver DiseaseHepatitis
Pain & clicking of jaws when eatingProsthetic Joint
Other Medical Issues not listed above

Medication & Allergies

Are you taking any kind of medicine, drugs, or pills?
Please list:
Please list:

Are you allergic to or have you ever had an adverse reaction to local anesthetics?
Are you allergic to or have you ever had an adverse reaction to aspirin?
Are you allergic to or have you ever had an adverse reaction to latex?
Are you allergic to or have you ever had an adverse reaction to penicillin?
Are you allergic to or have you ever had an adverse reaction to other medications?
Please list all allergies and adverse reactions that you are aware of below:

Women Only

Is it possible that you are currently pregnant?
Are you nursing?
Are you currently taking birth control medicine?

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 Dr. Leonard J. Goldman, D.D.S.  or the staff responsible for any errors or omissions that I have made in the completion of this form.



I the undersigned understand and agree that regardless of my insurance status, I am ultimately responsible for the balance of this account for any professional service rendered. I will notify your office of any changes in this information as they may occur. THERE WILL BE ADDITIONAL CHARGES IF THIS ACCOUNT IS TURNED OVER TO OUR ATTORNEY FOR NON PAYMENT.

  
  Signature                                                                                                                 Date        

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