New-Patient-Registration PATIENT INFORMATIONHiddenName* First Last Preferred Name Date of Birth MM slash DD slash YYYY Age Sex Male Female Social security number* Mailing Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home phoneMobile phoneOtherHiddenEmail* Our office uses an electronic reminder system. How would you like to receive your reminder? Text Message Email Phone call How did you hear about our office? EMERGENCY CONTACTName First Last Phone NumberRelationship to patient DENTAL INSURANCEPolicy holder Name Date of Birth MM slash DD slash YYYY Social security number* Identification NumberGroup Number Employer SECONDARY INSURANCE (if applicable)Policy holder Name Date of Birth MM slash DD slash YYYY Social security number* Identification NumberGroup Number Employer DENTAL HISTORYWhat is the reason for your visit today? Are you apprehensive about dental treatment? Have you had problems with previous dental treatmentPlease SelectYesNoIf yes please describeAre you interested in: Whitening your teeth Braces/Invisalign Cosmetic treatment DENTAL HISTORYPrevious Dentist Phone numberWhen was your dental exam/cleaning? Do you have any immediate concerns/pain? Please circle YES or NO if you have, or ever had the following:Unhappy with appearance of your teeth Yes No Burning sensation in the mouth Yes No Unfavorable dental experience/fear Yes No Difficulty swallowing Yes No Preference for no dental anesthetic Yes No Unpleasant taste or odor in your mouth Yes No Difficulty/Reactions to dental anesthetic Yes No Jaw problems/pain/clicking/locking Yes No Orthodontic treatment/Braces Yes No Difficulty opening wide Yes No Periodontal (Gum) treatment Yes No Stiff neck muscles Yes No Bleeding Gums Yes No Tension headaches Yes No Bleeding Avoid brushing any parts of your mouth Yes No Clench or grind your teeth Yes No Sensitivity to temperature in the mouth Yes No Sore teeth Yes No ALLERGIES ASPIRIN, ACETAMINOPHEN, or IBUPROFEN PENICILLIN OTHER ANTIBIOTICS CODEINE/NARCOTICS LATEX FLUORIDE LOCAL ANESTHESIA METALS SULFA MEDICAL INFORMATIONPhysician or Clinic name PhonePlease circle YES or NO if you have, or ever had the following:Anemia Yes No Cough up blood Yes No Narcolepsy Yes No Angina Yes No Diabetes Yes No Kidney Disease Yes No Anxiety Yes No Epilepsy Yes No Liver Disease Yes No Arthritis Yes No Fainting Yes No Mitral Valve Prolapse Yes No Artificial joint/heart valve Yes No Fatigue Yes No Pacemaker Yes No Asthma Yes No GERD Yes No Radiation therapy Yes No Acid Reflux Yes No Headaches Yes No Respiratory Disease Yes No Back problems Yes No Heart attack Yes No Sleep Apnea Yes No Blood disease Yes No Heart Murmur Yes No Stroke Yes No Chemical dependency Yes No Hemophilia Yes No Thyroid Problems Yes No Glaucoma Yes No Hepatitis Yes No Tuberculosis Yes No Chemotherapy Yes No High blood pressure Yes No Ulcer Yes No Cancer Yes No HIV/AIDS Yes No Depression Yes No Have you had any serious type of illness or operation? Yes No If Yes describeIf you have a disease, condition or problem not previously listed, please describeHave you ever taken Fosamax, Boniva, Actonel, or any other cancer medications? Yes No Do you use tobacco? Yes No Has your Doctor ever told you that you require a Pre-Medication? Yes No (Women) Are you currently pregnant or trying to? Yes No Nursing? Yes No Please list any/all medications you are currently taking;Patient name (Printed) SignatureDDS signatureDate MM slash DD slash YYYY FINANCIAL POLICYThank you for choosing Icon Dental Center as your dental health care provider. We are committed to providing the best dental care possible. Please understand that payment of your bill is considered a part of your treatment. The following statement explains our Financial Policy which we ask you to read, sign and return to us prior to your treatment. Please provide accurate and complete personal and insurance information prior to being seen by the dentist. All applicable co-pays, personal balances, both current and prior, are due at the time of service or upon receipt of invoice. We accept Cash, Check, Visa, Master card, Discover, Care credit and Health savings account cards. Regarding your Dental Insurance We participate in most insurance plans, however we require that the guarantor, the person who is financially responsible, is personally liable for all balances not covered by insurance. It is your responsibility to understand your dental benefits. Please be aware that some and perhaps all of the services provided may be non-covered services or may not be considered dentally necessary under your dental insurance. Please understand that insurance is always an estimate and never guarantee of coverage. Final determination will be made when the claim is received and processed by your insurance. We will file all insurance claims with the insurance provider you supply our office with. Please be sure to update our office of any changes in your insurance. Please also remember that insurance is a contract between the patient and the insurance company and ultimately the patient is responsible for payment in full. Your insurance company may need you to supply certain information directly in order to pay the claim. If you are uncertain about your current insurance policy benefits you should contact your plan to learn the details about your benefits, out-of-pocket expenses and, coverage limits.Initials: Cost of Treatment Treatment plans are customized for your individual care. To that end we want you to be aware of your financial investment into your care and do so by providing estimates of your out-of-pocket expenses based upon your plan. Please understand that any estimate given is just an estimation of costs as there are many factors that contribute to the treatment and insurance coverage.Initials: Missed appointments To provide the best care possible for each patient, Icon dental center requires a 48 hours business day notice for any cancelations or changes, to avoid a charge. Appointments that are missed or canceled without notice will be assessed with a $100.00 per hour scheduled, fee.Initials: Minors The parent(s), guardian(s), or Financial Guarantors is responsible for full payment and will receive the billing statements. A signed release to treat may be required for unaccompanied minors.Initials: Past Due Accounts I/We agree to pay all attorney’s fees, court costs, and filing fees, which may be assessed by any collection agency or law firm retained to pursue the matter. Additionally, past due balances shall accrue interest at the rate of twelve (12%) percent per annum.Initials: Address Changes It is our policy to provide invoices for any amounts owed on your account. We send all correspondence to the address information you provide, so please advise us anytime there is a change to your address, telephone number or other contact information. Returned Checks For checks returned to us as unpaid by your bank, we will charge a $25.00 fee. I authorize Icon Dental Center to release pertinent dental/medical information to my insurance company when requested, or to facilitate payment of a claim. I authorize my insurance benefits to be paid directly to Icon Dental Center. I have read the Financial Policy. I understand and agree to the Financial PolicyFinancial Guarantor- Printed Name SignatureDate MM slash DD slash YYYY PRIVACY POLICY – ACKNOWLEDGEMENT OF RECEIPTI certify that I have received a copy of Icon Dental Center Notice of Privacy Practice. The Notice of Privacy describes the types of uses and disclosures of my protested health information that might occur in my treatment, payment for services or in the performance of office’s health care operations. The Notice of Privacy Practices also describes my rights and Icon Dental Center’s duties with respect to my protected health information. The Notice of Privacy Practices is posted in the facility. Icon Dental Center reserves the right to change the privacy practices that are described in the Notice of Privacy ractices. If privacy practices change, I will be offered a copy of the revised Notice at the time of my first visit after the revisions become effective. I may also obtain a revised Notice by requesting that one be mailed to me. ADDITIONAL DISCLOSURE AUTHORITY I hereby specifically authorize disclosure of my protected health care information to the persons indicated below; this may include appointment information, insurance and sensitive personal information to;Any member of my immediate family Yes No Spouse Only Yes No Other (Specify) Yes No Patient name (Printed) SignatureDate MM slash DD slash YYYY 15964
