Patient Registration

Step 1 of 5

Mrs.Ms.Mr.Dr.

Date

First Name

Middle Initial

Last Name

Preferred Name

Mailing Address

City

State

Zip Code

E-Mail Address

Home Phone

Cell Phone

Birth Date

Marital Status

Emergency Contact Name

Emergency Contact's Phone Number

Person Responsible for Account

Relationship to Patient

Phone Number of Responsible Person

Social Security Number of Person Responsible For Account

Date of Birth of Person Responsible for Account

Whom may we thank for the Referral? (optional)

Name of Dentist

Name of Medical Physician

Address of Your Medical Physician

Phone Number of Medical Physician

Date of Your Last Medical Physical Examination

Preferred Pharmacy Name

Pharmacy Phone Number

The above information on this form has been accurately answered and is true to the best of my knowledge. I understand that providing incorrect information can be dangerous to my or the patient's health. I understand that it is my responsibility to inform Camelback Periodontics and the rendering Dentist of the dental office of any changes in my or the patient's medical status.

Date

Step 2 of 5

Financial Policy

Primary Dental Insurance

Subscriber Name:

Subscriber Date Of Birth:

Subscriber Id Number:

Relationship To Patient:

Insurance Company Name:

If you have MetLife Insurance, please enter your SSN:

Group Number:

Insurance Company Phone Number:

Name Of Subscriber Employer:

Secondary Dental Insurance

Subscriber Name:

Subscriber Date Of Birth:

Subscriber Id Number:

Relationship To Patient:

Insurance Company Name:

Group Number:

Insurance Company Phone Number:

Name Of Subscriber Employer:

Financial Policy Agreement

Thank you for choosing Camelback Periodontics to serve your dental needs. We are committed to providing you with the highest quality lifetime dental care, so that you may attain optimum oral health. The following is a statement of our financial policy, which we require that you read, agree to, and sign prior to any treatment. Please note that payment of your bill is considered part of your treatment. Payment is due at the time service is provided. Our office accepts cash, personal checks, and all major credit cards. Outside financing is available upon request and preapproval. Please ask if you would like more information about financing options.

Do You Have Insurance? Camelback Periodontics may not be contracted with your insurance company. As a courtesy to you we will help you process your insurance claims. Please understand that we will provide an insurance estimate to you; however, it is not a guarantee that your insurance will pay exactly as estimated. Any insurance reimbursement is limited to the information your insurance company is willing to share prior to treatment. Because your insurance reimbursement is based on a contract between you, your employer, and the insurance company, Camelback Periodontics is only able to advocate on your behalf. Under no circumstances will any insurance company guarantee payment prior to treatment. While your insurance company is concerned with limitation and policy issues in relation to the premiums paid, Camelback Periodontics primarily focuses for your health. Camelback Periodontics is committed to maximizing your return from the insurance company and providing you with the highest levels of service and clinical care.

All charges you incur are your responsibility regardless of your insurance coverage. We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your insurance company. Your insurance policy is a contract between you, your employer, and your insurance company. Our office is not a party to that contract.

I understand that any fees incurred will be my responsibility and I will keep my account current. Any remaining balance over 90 days will accrue service charges. A cancellation fee of $100.00 may be assessed to your account for missed appointments or rescheduling without at least 24 hours notice.

CONSENT: I HAVE READ, UNDERSTAND AND AGREE TO THE ABOVE TERMS AND CONDITIONS. I AUTHORIZE MY INSURANCE COMPANY TO PAY MY DENTAL BENEFITS DIRECTLY TO MY DENTAL OFFICE.

Patient/Guardian Signature:

Date:

Step 3 of 5

Medical History

Date

Check all of the following that you may have had in the past or that currently apply to you:

AIDS/HIV PositiveAlzheimer's DiseaseAnemiaAnginaArthritis/GoutArtificial Heart ValveArtificial/Orthopedic JointAsthmaBlood DiseaseBlood TransfusionBruise EasilyCancerChemotherapyChest PainsCold Sores/Fever BlistersCongenital Heart DiseaseConvulsionsCortisone MedicineDental ImplantsDiabetes: A1CDrug AddictionElevated CholesterolEmphysemaEpilepsy Or SeizureExcessive BleedingFainting/Dizzy SpellsFrequent HeadachesGastric Bypass surgeryGlaucomaHay FeverHeart AttackHeart MurmurHeart Pace MakerHeart Trouble/DiseaseHemophiliaHepatitis A, B, or CHepatitisHigh Blood PressureHives Or RashIrregular HeartbeatKidney ProblemsLeukemiaLiver DiseaseLow Blood PressureLung DiseaseMitral Valve ProlapseParathyroid DiseasePsychiatric CareRadiation TreatmentsRecent Weight LossRenal DialysisRheumatic FeverScarlet FeverShinglesSickle Cell DiseaseSinus Trouble/InfectionsSleep Apnea-CPAP?Sores or Growths in mouthStrokeThyroid DiseaseTuberculosisTumors Or GrowthsOther

Do you have low bone density (osteoporosis, osteopenia, metastatic bone disease)?

YesNo

Are you allergic or have you reacted adversely to any of the following medications?

AspirinCodeineDarvonErythromycinLatexLocal AnestheticNitrous OxidePenicillin/AmoxicillinPercodanSulfaTetracyclineValiumOther

Have you ever taken any of the following medications? Provide Start and Stop date

ActonelAlendronateArediaBonivaFosamaxReclastRisedronateZometaProlina/DenosumabHerbal SupplementsIbuprofenNSAIDS

Medication Start and Stop Date

Are you currently taking any medications? If yes please list:

Do you need Antibiotics prior to receiving Dental Care? If so, what type/dosage?

Do you take Coumadin or Plavix or any other blood thinner? If yes, do you know your typical INR?

How would you describe your present health:

ExcellentGoodFairPoorDon't know

When was your last visit with your Primary Care Physician?

Are you currently under a physician's care? If yes please list for what:

Has there been any change in your general health in the past year? If yes, please explain:

Have you ever had any serious illness, hospitalization or condition not listed above in the last 5 years?

What is your current weight?

What is your height?

Is there a history of diabetes in your family? If yes, who:

Are you a past or present smoker/vaper? If yes, how many per day?

YesNo

Do you Chew Tobacco?

YesNo

Do you have any history of substance abuse or do you currently use recreational drugs?

YesNo

For Women, Check All That Are Appropriate:

I am Pregnant/Trying to get pregnantI am NursingI am Taking Birth Control Pills

The above information on this form has been accurately answered and is true to the best of my knowledge. I understand that providing incorrect information can be dangerous to my or the patient's health.

Patient/Guardian Signature:

Date:

Blood Pressure/Heart Rate

Doctor's Signature:

Date:

Step 4 of 5

Dental History

Date

Date of Last Dental Cleaning?

What is the frequency of cleanings?

How Many Times a Day do you Brush Your Teeth?

How Many Times a Day do you Floss?

What Type of Tooth Brush do you Use?

Do you use a Water Pik?

YesNo

Please Rate Your Current Dental Health:

ExcellentGoodFairPoor

How Would you Rate Your Smile:

ExcellentGoodFairPoor

Are Your Teeth Sensitive to:

HeatColdSweetsPressureBrushingFlossing

Yes / No (If Yes, Please Explain)

Do you experience dry mouth?

YesNo

Do Your Gums Bleed?

YesNo

Would you prefer to be Sedated for Dental Treatment?

YesNo

Are You concerned with Tooth Loss or Wearing Dentures?

YesNo

Have you ever had Orthodontic Treatment (Braces)?

YesNo

Have you ever had trouble getting Numb and/or had Reactions to Local Anesthetic?

YesNo

Have you noticed any Loose or Shifting Teeth?

YesNo

Have you noticed any Bad Tastes or Bad Breath?

YesNo

Have any of your family members had Advanced Gum Disease, Wear Partials or Dentures?

YesNo

Do you have any Clicking, Popping, and/or Discomfort in the Jaw?

YesNo

Do you Clench and/or Grind Your Teeth?

YesNo

Do you wear a Nightguard or Appliance?

YesNo

Are you experiencing any discomfort?

YesNo

Have you ever had Periodontal (Gum) treatment?

YesNo

Have you ever had Deep Cleaning (Scaling with Local Anesthesia)?

YesNo

Have you had problems associated with previous Dental Treatment?

YesNo

The above information on this form has been accurately answered and is true to the best of my knowledge. I understand that providing incorrect information can be dangerous to my or the patient's health.

Patient/Guardian Signature:

Date:

Step 5 of 5

Acknowledgment of Receipt of Notice of Privacy Practices

*You May Refuse To Sign This Acknowledgement*

I, have received a copy of this office's Notice of Privacy Practices.

Please Print Your Name

Signature

Date

Authorization to Release Information

I authorize the following person(s) to have access to information covered under the Privacy Act.

Person 1

Please Print Name

Relationship

Phone Number

Person 2

Please Print Name

Relationship

Phone Number

Person 3

Please Print Name

Relationship

Phone Number