This form is HIPAA compliant to ensure privacy.

Rockwall Pediatric Dentistry

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New Patient Registration Form

Patient Information

Sex:
First Name:

Date of Birth:

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

 Email:

 
Street:
Home Tel. #:
City:
School:
State:
Referred By:
Zip:
For Doctor:
 
Physician:
Emergency Contact:
Physician Phone #:
 Relation:
 
Name of Siblings:
 
 

Have you ever been a patient of our practice?

How were you referred to our office?



Referral Name:

Are Parents:

Method of Personal Payment:

 

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

Title:

Social Security #:

First Name:

Date of Birth:

Middle Initial:

Tel. #:

Last Name:

Mobile Tel#:

 

Street:

Employer Name:

City:

Emp. Tel. #:

State:

Relation:

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:

General Health

Have there been any changes in your general health in the past year?
If yes, please explain:
Are you under the care of a physician?
Date of last visit:
Name of physician:
What was the purpose of your visit?
Are you under the care of a dentist?
Date of last visit:
Name of dentist:
Have you had any illness, operation or been hospitalized?
Please List:
Do you have injuries or inflamed areas, growths or sore spots in or around your mouth?
Where:
Do you have a heart valve replacement or vascular graft?
Where:
Is this visit related to an accident?
When was the accident?
Are there conditions that the doctor should be aware of?
Please List:

Conditions 

High / Low blood pressureChest pain / angina
Heart Murmur / Mitral Valve ProlapseHandicaps / Disabilities
Heart surgeryADHD / ADD
Behavior or learning difficultiesBlood 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
Infectious mononucleosisDelay in healing
Malignant hyperthermiaHIV/AIDS
I smokeDifficult breathing / other lung trouble
Bronchitis / chronic coughAsthma
Hay fever / sinus problemsTuberculosis
Food / Dye AllergiesThyroid trouble
Low blood sugarDiabetes
Stomach ulcersGallbladder trouble
Blood disorder such as anemiaBruise easily
Bleeding tendency (abnormal bleeding)Cleft Lip / Palate
Convulsions / epilepsyFainting spells
Kidney trouble / DialysisEye Disease / Glaucoma
Contact lensesHepatitis
Pain & clicking of jaws when eatingProsthetic Joint

Medication & Allergies

Are you taking any kind of medicine, drugs, or pills?
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:
Other Medical Issues not listed above:



Fees and Payments
We make every effort to keep down the cost of your dental care.  An estimate of the charge for any procedure or surgery you may require will be given to you. If you have any dental and/or medical insurance we will be glad to help you understand your policy.

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 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 Rockwall Pediatric Dentistry  or the staff responsible for any errors or omissions that I have made in the completion of this form.

AUTHORIZATION FOR TREATMENT
I authorize this dental office to perform examination (including necessary radiographs
[x-rays]), and after explanation, the necessary dental services deemed appropriate for the care of the above named child. In addition, I agree to pay for all charges incurred resulting from said dental treatments, including insurance deductibles and copayments. 


  
   Signature:                                                                                       Date:        
  
   Relationship to child:                                                                                      

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