This form is HIPAA compliant to ensure privacy.

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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 Phone:
City:
Work Phone:
State:
Ext.:
Zip:
Mobile Phone:
Employer Name:
Occupation:
 
Marital Status:
 
Dentist Name:
Emergency Contact:
Dentist Phone:
 Relation:
Physician Name:
Home Phone:
Physician Phone:
Work Phone:
Spouse Name:

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 Phone:
 

Street Address:

 Mobile Phone:

City:

Employer Name:

State:

Work Phone:

Zip:

(if other) Relation:

Spouse or Guarantor Info (if different from above)
Title:

Social Security:

First Name:

Home Phone:
Middle Initial:

Mobile Phone:
Last Name:

Employer Name:

Street Address:

Work Phone:

City:

Relation:

State:

 

Zip:


Primary Dental Insurance

Employer Name:

Group Number:

Work Phone:

Subscriber Name:

Ins. Co. Name:

Subscriber Birthday:

Insurance Phone:

Contract ID:
Insurance Address:    
Relationship to Patient:

Primary Medical Insurance

Employer Name:

Group Number:

Work Phone:

Subscriber Name:

Ins. Co. Name:

Subscriber Birthday:

Insurance Phone:

Contract ID:
Insurance Address:    
     Relationship to Patient:

Secondary Insurance
Type of Insurance:

Employer Name:

Group Number:

Work Phone:

Subscriber Name:

Ins. Co. Name:

Subscriber Birthday:

Insurance Phone:

Contract ID:
Insurance Address:    
     Relationship to Patient:

General Health
Are you in relatively good health?
Height:
Weight:
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:
For what are you being treated?
Have you had any illness, operation or been hospitalized in the past five years?
If yes, please explain:
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 any health conditions that the doctor should be aware of?
Please List:
Do you smoke?

Conditions (a Y or N must be selected)
High Blood PressureChest Pain / Angina
Heart Murmur / Mitral Valve ProlapseIrregular Heartbeat
Cardiac PacemakerHeart Surgery
StrokeHeart Attack(s)
Blood TransfusionSwollen Ankles
Chronic Fatigue / Night SweatsRheumatic Fever
Artificial Heart ValvesProblems with the Immune System
Sexually Transmitted DiseasesCancer / Tumor
Radiation Treatment / ChemotherapyInfectious Mononucleosis
Delay in HealingMalignant Hyperthermia
AIDS / HIVDifficult Breathing / Other Lung Trouble
Bronchitis / Chronic CoughAsthma / Emphysema
Hay Fever / Sinus ProblemsTuberculosis
Thyroid TroubleLow Blood Sugar
DiabetesStomach Ulcers
Gallbladder TroubleBlood Disorder such as Anemia
Bruise EasilyBleeding Tendency (Abnormal Bleeding)
Mental Health ProblemsHistory of Drug / Alcohol Dependency
Convulsions / EpilepsyFainting Spells
Kidney Trouble / DialysisEye Disease / Glaucoma
Contact LensesHepatitis or Liver Problems
Pain & Clicking of Jaws when eatingProsthetic Joint (Hip, Knee, etc.)
OsteoporosisOther Medical Conditions

Medication & Allergies
Are you taking any kind of medicine, drugs, or pills?
Please list:
Have you ever taken bisphosphonates such as Zometa, Fosamax, Actonel, Boniva, or Skelid?
Please list and state when they were taken:

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?
Are you allergic to eggs, soy, or dairy products?
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 Payment Policy
We make every effort to keep down the cost of your oral surgical care.  If possible, an estimate of your charges for your procedure or surgery will be given to you upon request. In order for us to continue to provide Quality Care for our patients, we require payment of fees on the date of service. As a service to you we will be happy to code and submit charges to applicable dental insurance companies. Please remember, the contract is between you and your dental insurance provider. The patient is responsible for knowing their coverage.  

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 David M. Ivey, DDS  or the staff responsible for any errors or omissions that I have made in the completion of this form.

Authorize to Release Health Information to Family Members & Close Friends. I authorize David M. Ivey, DDS, PC to disclose health information to the following individuals to the extent necessary to help with healthcare or payment for healthcare.

  
  Name                                     Date of Birth        

  
  Name                                     Date of Birth        

  
  Signature of Parent/Guardian/Patient                                                     Date        

  
  Relationship of Patient Representative to Patient

Printing your name in the Signature box above acts as your signature. This form will not submit without your printed name.

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