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Patient_registration

PATIENT REGISTRATION
Patient Information:

Today’s Date:_____________
E-mail Address:_______________________________________________
Home Phone #__________________ Cel Phone #___________________Work Phone #___________________ Ext #______
Name______________________________________ I prefer to be cal ed_____________________Birthdate_______________
Address______________________________________City__________________________State__________Zip______________
Employer_____________________________________Soc.Sec.#______________________
Sex_____Marital Status: S___M___W___D___ Spouse’s Name_________________________Spouse’s Birthdate_____________
Spouse employed by__________________________________Spouse Soc.Sec.#______________________________________
Whom may we thank for referring you?_______________________________________________________________________
Responsible Party Information:
Name of Responsible Party__________________________________ to Patient____________________Birthdate____________
(If different than patient)
Address_______________________________________City_________________________State___________Zip_____________
Home Ph#__________________
Insurance Information:
Primary Insurance:
Name of Insured____________________________Employer____________________________Soc.Sec.#___________________
Name of Dental Insurance Co.__________________________________________Group #_______________________________
Address to send claims to:___________________________________________________________________________________
(or provide copy of dental ins. card)
Secondary Insurance:
Name of Insured____________________________Employer____________________________Soc.Sec.#___________________
Name of Dental Insurance Co.__________________________________________Group #_______________________________
Address to send claims to:___________________________________________________________________________________
(or provide copy of dental ins. card)

Dental History:
Why have you come to the dentist today?______________________________________________________________________
Are you in pain? ___Yes ___ No
Do you require antibiotics before dental work? ___Yes ___No Your current dental health is ___Good ___Fair ___Poor Have you ever had periodontal disease? ___Yes ___No Are your teeth sensitive to heat, cold, or anything else?_________ Do you have mobility in your teeth? ___Yes ___No Previous/Present Dentist___________________City____________ Do you have popping or clicking in your jaw?___Yes ___No Last visit date______________
Do you grind or clench your teeth? ___Yes ___No
Would you like fresher breath? ___Yes ___No Would you like whiter teeth? ___Yes ___ No
Are you happy with the way your smile looks? ___Yes ___No
If not, what would you change?________________________________________________________________________________
MEDICAL HISTORY
Physician’s Name____________________________________City_____________________Date of Last Physical_____________
Are you sensitive or allergic to any of the following? (Please check if Yes)
Aspirin _____ Barbiturates_____Codeine _____ Latex _____ Sedatives _____
Dental Anesthetics _____ Jewelry/Metals _____
Any Antibiotics: E-Mycin____ Penicil in____ Sulfa____Tetracycline____Other____ Please List_____________________________
Have you had any joint replacements? Y___N___
Are you currently taking any of the following blood thinners? Y___N___ Coumadin, Warfarin, Plavix, Heparin, Lovenox,
Aggrenox, Aspirin If Yes, please circle the one you are taking

Have you ever had any of the fol owing? (Please check if Yes)
___AIDS-HIV
Please list any medications you are taking or give ___Artificial Heart Valves ___Artificial Joints ___High Blood Pressure ___Hearing problems Do you suspect that you are pregnant? Y___N___ Pregnancy Due Date_________Are you taking birth control pil s? Y___N___ Are you under the care of a physician? ___________________For what conditions?________________________________ Is there anything else we should know about your medical history?_____________________________________________ The above information is accurate and complete to the best of my knowledge. I wil not hold my dentist or any member of his staff responsible for any errors or omissions that I may have made in the completion of this form. I authorize the dentist to release any information including diagnosis and the records of treatment to my insurance company and or health practitioners. I agree to be responsible for payment of al services rendered on my behalf or my dependents. SIGNATURE_____________________________________________________________________________________ DATE________________ I have read my medical history dated _______________ and confirmed that it states past and present medical condition Signature_________________________________________________Date_______________ I have read my medical history dated _______________ and confirmed that it states past and present medical condition Signature_________________________________________________Date_______________ I have read my medical history dated _______________ and confirmed that it states past and present medical condition Signature_________________________________________________Date_______________ 217 Market St. | GALVA IL, 61434 | (309) 932-2000 Written Financial Policy
Thank you for choosing Galva Family Dentistry. Our primary mission is to deliver the best and most comprehensive dental care available. An important part of the mission is making the cost of optimal care as easy and manageable for our patients as possible by offering several payment options. Payment Options:
- Cash, Check, Visa, Mastercard or Discover Card o Allow you to pay over time with NO INTEREST¹ (over 3-18 months) o No annual fees or pre-payment penalties Galva Family Dentistry requires payment on the date of service unless other arrangements have been made. For patients with dental insurance we are happy to work with your carrier to maximize your benefit and directly bill them for you.³ We require payment of any deductible and/or copay on the date of service. This can also be taken care of with the “credit card authorization” form. If you have any questions, please do not hesitate to ask. We are here to help you get the dentistry you want or need. I understand this policy and agree to pay for all services rendered on my behalf or my dependents. ¹If paid within the promotional period. Otherwise, interest assessed from purchase date. Minimum monthly payment required. ²Subject to credit approval ³However, if we do not receive payment from your insurance carrier within 60 days, you will be responsible for payment of your treatment fees and collection of your benefits directly from your insurance carrier.
Cancellation Policy

We would greatly appreciate a 48 hour notice from any patient (or patient representative) should
they need to reschedule or cancel an appointment. We reserve the right to apply a cancellation fee
if this policy is not respected.

Source: http://galvafamilydentistry.com/PATIENT_REGISTRATION.pdf

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