Patient Registration

General Information

First Name
Last Name
Preferred Name
Responsible Party
Address
Address2
City
State
Zip
Phone
Sex
Marital Status
Birth Date
Drivers License Number
Email
Would you like to receive correspondences via e-mail?

Medical History

Are you under a physicians care now?
If Yes
Have you ever been hospitalized or had a major operation?
If Yes
Have you ever had a serious head or neck injury?
If Yes
Are you taking any medications, pills, or drugs?
If Yes
Do you take, or have taken, Phen-Fen or Redux?
If Yes
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
If Yes
Are you on a special diet?
Do you use tobacco?
Women: Are you...
 Pregnant/Trying to get pregnant?  Nursing?  Taking oral contraceptives?
 
Are you allergic to any of the following?
 Aspirin  Penicillin  Codeine  Acrylic
 Metal  Latex  Sulfa Drugs  Local Anesthetics
 
Other?
Do you use controlled substances?
If Yes
Do you have, or have you had, any of the following?
 AIDS/HIV Positive  Cortisone Medicine  Hemophilia  Radiation Treatments
 Alzheimer's Disease  Diabetes  Hepatitis A  Recent Weight Loss
 Anaphylaxis  Drug Addiction  Hepititis B or C  Renal Dialysis
 Anemia  Easily Winded  Herpes  Rheumatic Fever
 Angina  Emphysema  High Blood Pressure  Rheumatism
 Artificial Heart Valve  Excessive Bleeding  Hives or Rash  Shingles
 Asthma  Fainting Spells/Dizziness  Irregular Heartbeat  Sinus Trouble
 Blood Disease  Frequent Cough  Kidney Problems  Spina Bifida
 Blood Transfusion  Frequent Diarrhea  Leukemia  Stomach/Intestinal Disease
 Breathing Problems  Frequent Headaches  Liver Disease  Stroke
 Bruise Easily  Genital Herpes  Low Blood Pressure  Swelling of Limbs
 Cancer  Glaucoma  Lung Disease  Thyroid Disease
 Chemotherapy  Hay Fever  Mitral Valve Prolapse  Tonsillitis
 Chest Pains  Heart Attack/Failure  Osteoporosis  Tuberulosis
 Cold Sores/Fever Blisters  Heart Murmur  Pain in Jaw Joints  Tumors or Growths
 Congenital Heart Disorder  Heart Pacemaker  Parathyroid Disease  Ulcers
 Convulsions  Heart Trouble/Disease  Psychiatric Care  Venereal Disease
 Yellow Jaundice  
Have you ever had any serious illness not listed?
If Yes
Comments

Consent

I hereby authorize doctor or designated staff to take x-rays, study models, photographs, and any other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of (patient's name)'s dental needs.


Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.


I consent to the use of appropriate medication or therapy as deemed necessar. I fully understand that using anesthetic agents embodies a certain risk.


I agree to be responsible for and understand that I am responsible for payment of all services rendered on my behalf or my dependents. I understand that I am responsible for whatever my insurance company does not pay and that payment is due at the time of service unless other arrangements have been made. In the event payments are not received within 60 days of the date of billing, I understand that a month 1 1/2% finance charge (18% APR) will be added to my account.


I authorize the rendering of diagnostic and treatment procedures, including local anesthesia, by Drs. Jimmie & Luanne Anderson, which in their professional judgement may be deemed necessary or beneficial.


 

I further understand that this consent will remain in effect until such time that I choose to terminate it.
 Implants  Crowns/Bridges/Veneers
 Composites/Amalgams  Root Canal Therapy
 Extractions  Sealants
 Dentures/Partials  Bite Splint/Guard
 Whitening  Anesthetic
 Exams  Prophylaxis (cleaning)
 X-Rays  Fluoride
 Perio Maintenance  Scaling and Root Planing
 

 

I authorize the rendering of diagnostic and treatment procedures, including local anesthesia, by Drs. Jimmie & Luanne Anderson and Staff, which in their professional judgement may be deemed necessary or beneficial.

 

I further understand that this consent will remain in effect until such time that I choose to terminate it.

 

Office Policy

Payment Policy

Please be aware that you are legally responsible for the payment of all charges. We operate on a fee-for-service basis and therefore payment is required at each appointment. We accept Cash, Check, Visa, Mastercard, and Discover.

 

For our patients with insurance, we will file with your primary claims for you as a courtesy; however, we do expect your portion at the time of treatment. If we do not receive payment from your insurance company within 60 days from the date of service, you will be expected to pay for all dental services in full. All balances over 90 days are subject to a 1.5% service charge. In the event your account becomes past due, you will be responsible for any recovery fees. 

 

Please remember that any insurance policy is a contract solely between you as a patient and the carrier of your insurance. Please make yourself aware of the benefits of your specific policy.

 

Appointment Policy

We do see all patients by appointment only. If you are unable to keep a scheduled appointment, we ask for a minimum of forty-eight (48) hours notice. If the office is closed when you call, please leave a message with our answering service.