New Patient Adult Registration Form Full St. Charles, IL

Patient Information

Patient Name (required)

Date

Gender
MF

Birth Date: (required)

Social Security #:

Marital Status

MarriedSingleDivorcedWidowed

Phone:

Address:

Employed By:

Preferred Confirmation Method:Home PhoneWork PhoneCell PhoneE-MailText Msg

Email Address:

Referred By:

Health Information

X Artificial Heart Valves X Artificial Joints X AIDS/HIV X Asthma X Cancer X Diabetes X Diet Controlled Diabetes X Insulin Dependant Diabetes X Anemia X Epilepsy/Seizures X Emphysema

X Fainting/Dizziness X Heart Attack X Cardiac Stent X Heart Problems X Pacemaker X Hemophilia/Bleeding Disorder X Hepatitis X High Blood Pressure X Low Blood Pressure X Tuberculosis X Arthritis/Rheumatism X Back Problems X Blood Disease X Drug/Alcohol Abuse X Cocaine Use

X Cortisone Treatments X Glaucoma X Kidney Disease X Liver Disease X Psychiatric Care X Stroke X Thyroid Problems X Ulcer(s) X Headaches X Snore/Sleep Apnea X Venereal Disease
AllergiesX Amoxicillin Allergy X Aspirin Allergy X Codeine Allergy

X Dental Anesthetics X Latex Allergy X Penicillin Allergy X Tetracycline Allergy X Sulfa Drug Allergy X Other Drug Allergies

Do you smoke?YesNo

How many per day?

Do you use chewing tobacco?YesNo

Do you vape?YesNo

How often?

Are you or have you ever taken Bisphosphonate therapy drugs: Actonel, Boniva, Fosamax or Didronel for osteoporosis or certain types of cancer?YesNo

Are you now under care of a physician? YesNo

If yes, please explain

Name of Physician:

Phone:

Are you pregnant?YesNo

What week?

Are you nursing?YesNo

Are you taking birth control pills?YesNo

Are you currently taking any medications, including over-the counter & reason for taking?YesNo

If yes describe for what condition

List:

In Case of an emergency who should be notified? Name:

Phone:

Relationship to patient:

It is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and/or treatment.

Please sign with mouse or finger:

Date:

Person Responsible For Payment

Name:

MaleFemale

MarriedSingleOther

Social Security #:

Birth Date:

Phone (Home):

(Work):

Ext:

Cell:

Address:

City:

State:

Zip Code:

Credit Card Authorization (optional)

Credit Card Number:

Circle One:MCVisaDiscoverAmEx

Expiration Date:

3 digit security code:

Name On Card

Signature(to be signed at the office)

_________________________________

Insurance Information

Primary

Name of Insured:

Is Insured a patient?YesNo

Insured's Birth Date:

ID #:

Group #:

Insured's Address:

Insured's Employer Name/Phone:

Address:

Patient's relationship to insured:SelfSpouseChildOther

Insurance Plan Name and Address:

Secondary

Name of Insured:

Is Insured a patient?YesNo

Insured's Birth Date:

ID #:

Group #:

Insured's Address:

Insured's Employer Name/Phone:

Address:

Patient's relationship to insured:SelfSpouseChildOther

Insurance Plan Name and Address:

Consent for Services

I authorize my insurance company to pay to the dentist or dental group all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions whether manual or electronic.

I authorize the dentist to release all information necessary to secure payment of benefits.

A service charge of 1 ½% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 90 days, unless previously written financial arrangements are satisfied.

It is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services.

I have received a copy of the Notice of Privacy Practices of Michele S. Horton, D.D.S.,FAGD , PC and have been given an option to opt out.

I have read the above conditions of treatment and payment and agree to their content.

Please sign with mouse or finger:

Patient, Parent, Guardian:

Date:

Relationship to Patient:

Guarantor of Payment/Responsible Party:

Date:

Relationship to Patient:

Dental History

Patient Name (required)

Birthdate:

What is the reason for your visit today ?

Are you in pain ?YesNo

Date of your last dental visit:

What was done then:

Previous dentist (name & location):

Date of your last full mouth x-rays:

Last dental cleaning:

How often do you brush your teeth:

How often do you floss your teeth:

Do you use fluoridated toothpaste?YesNo

Name:

Primary source of drinking water:City WaterBottled WaterWell WaterReverse Osmosis

What types of beverages do you typically drink between meals:

Do you use tobacco?YesNo

Type:

Amount:

Number of years:

How soon after waking do you use tobacco:

Previous attempts to quit:YesNo

Number of attempts:

Do you get cold sores:

YesNo

Do your gums bleed while brushing or flossing:

YesNo

Are your teeth sensitive to hot or cold liquids/foods:

YesNo

Are your teeth sensitive to sweet or sour liquids/foods:

YesNo

Do you feel pain in any of your teeth :

YesNo

Do you have any sores or lumps in or near your mouth

YesNo

Have you had any head, neck, or jaw injuries

YesNo

Have you ever experienced any of the following problems in your jaw?

Clicking

YesNo

Pain (joint, ear, side of face)

YesNo

Difficulty opening or closing

YesNo

Difficulty chewing

YesNo

Do you have frequent headaches

YesNo

Do you clench or grind your teeth

YesNo

Do you bite your lips or cheeks frequently

YesNo

Have you noticed any loosening of your teeth

YesNo

Does food tend to become caught between your teeth

YesNo

Have you ever had periodontal treatment (gums)

YesNo

Have you had orthodontics (braces)

YesNo

Do you wear denture(s) or partial(s)

YesNo

Do you like your smile

YesNo

Would you like to whiten your teeth

YesNo

If you could change anything about your smile, what would you change ?

Please sign with mouse or finger:

Date:

Drs Horton & Vranas, INFORMATION RELEASE AND AUTHORIZATION FORM

AUTHORIZATION FOR RELEASE OF INFORMATION

Patient

Date of birth:

I authorize the release of information including the entire contents of dental record, including diagnosis, treatment details and financial information.

This information may be released to:

Spouse

Child(ren)

Other

Information is not to be released to anyone

I understand that I have the right to revoke this Authorization, in writing, at any time by notifying this office. Such revocation will not affect actions taken by the requesting person prior to the date he or she received the written revocation. I also understand information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and will no longer be protected by this rule. I understand that my dental provider cannot condition treatment on whether I sign this Authorization.

This Authorization will remain in effect until terminated by me in writing or until the following date:

MESSAGES

Please call:

my homemy workmy cell

If unable to reach me:

You may leave a detailed message

please leave a message asking me to return call

Other

X I agree to two way text messaging with Horton & Vranas DDS until I inform them to STOP.

It is my responsibility to notify Drs Horton & Vranas of changes and to complete a new form.

Please sign with mouse or finger:

Date

Patient/Authorized Person (Please Print)

Relationship to Patient

AUTHORIZATION FOR TREATMENT OF A MINOR BY DELEGATED PERSONS

I hereby authorize that the following persons have my permission to seek and authorize dental treatment of the above named minor child in my absence and that his/her protected dental information may be shared.

Name:

Relationship to Patient

Phone Number:

Name:

Relationship to Patient

Phone Number:

It is my responsibility to notify Drs. Horton & Vranas of changes and to complete a new form.

Please sign with mouse or finger:

Date

Patient/Authorized Person (Please Print)

Relationship to Patient