This form is HIPAA compliant to ensure privacy.

Bruce A. Mutchler, D.D.S. & Kathryn A. Lewis, D.D.S., LLC

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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:
Home Tel. #:
City:
Business 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:

 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:

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

Height:
Weight:
Reason for visit:
Name of previous dentist:
Phone:
Date of last visit:
Pain in jaw, face, or mouth
Bad breath
Frequent headaches
Lump or swelling in mouth
Teeth sensitive to cold / heat
Bleeding gums
Difficulty in opening mouth
Dry mouth
Jaw joint pain or sounds
Clenching or grinding teeth
Discolored teeth
Food wedging between teeth
Crooked teeth
Are you under the care of a physician?
Do you have a current medical problem?
Has there been a change in your health in the past year?
Have you ever been hospitalized or had a serious illness?

Conditions  (please  check  all  that  apply)

Rheumatic heart diseaseHeart murmur
Congenital heart problemsHip or other joint replacement
Heart valve replacementHeart surgery
Hepatitis or Liver diseaseDiabetes (sugar disease)
High blood pressureChronic sinus problem
Circulatory problemsHeart attack
Cancer or MalignancyDo you smoke
Do you use smokeless tabaccoAnemia
ArthritisEpilepsy
Kidney diseaseChronic ear infection
MeaslesMumps
Thyroid problemsTuberculosis
Cerebral palsyAsthma
Venereal diseaseHIV Positive
Are you pregnant

Medication & Allergies

Are you currently taking a blood thinner?
What are you taking?
Do you take any medicine to treat osteoporosis?
What are you taking?
Are you taking any medications or drugs?
What are you taking?
Are you allergic to any medications or drugs?
What are you taking?


Women Only

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

Family History (please  check  all  that  apply)






Fees and Payments
Our office accepts cash, checks, and all major credit cards. As a courtesy, we file with most major insurance companies. It is important that you bring all necessary information with you on your first visit; this includes employee and employer name, social security number, and date of birth of the employee. We do not believe insurance should ever be the deciding factor in your care; however, we will assist you with maximizing any benefits that might be available to you. We are a provider for many insurance companies, so please check with your carrier to verify that our office is a provider. We ask that any portion not covered by your plan be paid at each visit.

I give my consent to any advisable and necessary dental procedures and medications to be administered by the attending dentist or by the supervised staff for diagnostic purposes or dental treatment even though there are procedural risks. 
I authorize release of any information concerning my or (my child’s) health care, advice and treatment provided for the purpose of evaluating and administering claims, or to another dentist/doctor. 
I hereby authorize payment of insurance benefits directly to the dentist or dental group, otherwise payable to me. 
I understand and agree that, (regardless of my insurance status) I am ultimately responsible for the balance on my account for any professional services rendered. I also agree to pay any service charges and interest due to nonpayment of my account. 
I have read all the above information and completed the above answers. 
I certify this information is true and correct to the best of my knowledge. I will notify you of any changes in my health status or the above information. 
Patient Acknowledgements
I hereby acknowledge that I have been given the right to review this office's Notice of Privacy Practices. (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 Bruce A. Mutchler, D.D.S. & Kathryn A. Lewis, D.D.S., LLC  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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