Patient Registration Westborough Dentistree Patient Forms Westborough Dentistree 164 Milk St, Suite 6B, Westborough, MA 01581 Patient Registration First Name: Last Name: Middle Initial: Date of Birth: Social Security (Optional): Gender: Marital Status: Employment Status: Address: City, State, Zip: Mobile Phone: Home Phone: Office Phone: Email: Correspondence Preference: Email Phone Text Message Previous Dentist Name: Dentist Contact #: Emergency Contact Name: Emergency Contact #: Emergency Contact Relation: Responsible Party (parent/guardian/insurance policy holder) Name: Relation: Primary Insurance Insurance Name: Subscriber Name: Date of Birth: Subscriber Social Security (Optional): Member ID #: Group ID #: Patient Relationship to Insured: Self Spouse Child Other Address of Insured if different: City, State, Zip: Subscriber Phone #: Email ID: Secondary Insurance Insurance Name: Subscriber Name: Insured Date of Birth: Insured Social Security (Optional): Member ID #: Group ID #: Relationship to Insured: Self Spouse Child Other Address of Insured if different: City, State, Zip: Subscriber Phone #: Email ID: How did you come to know about us? Friend/Family Name: Insurance Directory: Internet Listing: Social Media: Other: Dental and Medical History 1. Diseases or Problems Do you have any of the following problems? If you answer YES to any of these 4 questions, please stop and return this form to the receptionist. Active Tuberculosis: Yes No Persistent cough (3+ weeks): Yes No Cough with blood: Yes No Exposure to Tuberculosis: Yes No 2. Dental Information Gums bleed when you brush or floss? Yes No Teeth sensitive to cold, hot, sweets, or pressure? Yes No Food or floss catch between your teeth? Yes No Is your mouth dry? Yes No Had any periodontal (gum) treatments? Yes No Ever had orthodontic (braces) treatment? Yes No Any problems associated with previous dental treatment? Yes No Is your home water supply fluoridated? Yes No Do you drink bottled or filtered water? Yes No If yes, how often? Select... Daily Weekly Occasionally Currently experiencing dental pain or discomfort? Yes No Do you have earaches or neck pains? Yes No Clicking, popping, or discomfort in the jaw? Yes No Do you brux or grind your teeth? Yes No Sores or ulcers in your mouth? Yes No Do you wear dentures or partials? Yes No Participate in active recreational activities? Yes No Ever had any serious injury to your head or mouth? Yes No 3. Dental Information Cont. Date of Last Dental Exam: What was done? Date of Last Dental X-ray: Reason for your visit: How do you feel about your smile? Great Good Average Poor 4. Medical Information Under the care of a physician? Yes No Physician Name: Phone: Address: Are you in good health? Yes No Any changes in your general health within the past year? Yes No If yes, what condition is being treated? Date of Last Physical Exam: Had a serious illness, operation, or been hospitalized in the past 5 years? Yes No If yes, what was the illness or problem? Taking or have taken any prescription or over-the-counter medications? Yes No If so, please list all natural or herbal preparations and/or diet supplements, including vitamins: Do you wear contact lenses? Yes No Joint Replacement – Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement? Yes No If yes, please list the date and any complications you may have had: Are you taking or scheduled to begin taking alendronate (Fosamax®) or risedronate (Actonel®) for osteoporosis or Paget’s disease? Yes No Since 2001, were you treated or are you presently scheduled to begin treatment with the intravenous bisphosphonates (Aredia® or Zometa®) for bone pain, hypercalcemia or skeletal complications? Yes No Do you use controlled substances (drugs)? Yes No Do you use tobacco (smoking, snuff, chew, bidis)? Yes No If so, how interested are you in stopping? Select... Very Somewhat Not Interested 5. Women Only Are you pregnant? Yes No If yes, how many weeks? Are you taking birth control/hormones? Yes No Are you nursing? Yes No 6. Allergies Are you allergic to, or have you had a reaction to, any of the following? To all YES responses, specify the type of reaction in the details below. Local Anesthetics: Yes No Codeine/ Other Narcotics: Yes No Iodine: Yes No Food: Yes No Barbiturates, Sedatives, Sleeping Pills: Yes No Penicillin/ Other Antibiotics: Yes No Latex (rubber): Yes No Hay Fever/ Seasonal: Yes No Other Details: 7. Diseases or Problems Cont. Artificial (prosthetic) heart valve: Yes No Previous infective endocarditis: Yes No Damaged valves in transplanted heart: Yes No Congenital heart disease (CHD) Unrepaired, cyanotic CHD: Yes No Repaired (completely) in last 6 mts: Yes No Repaired CHD with residual defects: Yes No Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD. Please answer all of the following questions: Abnormal bleeding:Yes No Angina:Yes No Asthma:Yes No Chronic pain:Yes No Chest pain upon exertion:Yes No Damaged heart valves:Yes No Eating disorder:Yes No Gastrointestinal disease:Yes No Heart attack:Yes No High blood pressure:Yes No Malnutrition:Yes No Ulcers:Yes No Osteoporosis:Yes No Tonsillitis:Yes No Rheumatoid arthritis:Yes No Rheumatic heart disease:Yes No Sinus trouble:Yes No Sleep disorder:Yes No Swelling of feet or ankles:Yes No Thyroid:Yes No AIDS/HIV Infection:Yes No Arteriosclerosis:Yes No Autoimmune disease:Yes No Cancer:Yes No Circulatory Problems:Yes No Diabetes:Yes No Excessive urination:Yes No Glaucoma:Yes No Hemophilia:Yes No Kidney problems:Yes No Mitral valve prolapse:Yes No Congenital heart defects:Yes No Rheumatic fever:Yes No Scarlet Fever:Yes No Skin Rash:Yes No Stroke:Yes No Anemia:Yes No Arthritis:Yes No Bronchitis:Yes No Cardiovascular disease:Yes No Chemotherapy:Yes No Radiation:Yes No Emphysema:Yes No Fainting spells/seizures:Yes No GERD/persistent heartburn:Yes No Jaundice, Liver Disease:Yes No Hepatitis:Yes No Low blood pressure:Yes No Night sweats:Yes No Pacemaker:Yes No Severe/ rapid weight loss:Yes No Severe headaches:Yes No STDs:Yes No SLE:Yes No Persistent swollen neck glands:Yes No Congestive heart failure:Yes No Blood transfusion:Yes No If yes, date: Mental health disorders: Yes No If yes, specify: Neurological disorders: Yes No If yes, specify: Recurrent infections: Yes No Type of infection: 8. Family History Any illness in the family – provide details, relationship to the person: 9. Social History Occupation: Caffeine Use (List type and how many times a day): Alcohol Consumption: Rarely Moderately Daily Socially None Smoking Status: Rarely Moderately Daily Socially None Recreational Drugs (name or type): HIV Risk Factors: 10. Previous Physician and Acknowledgement Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment? Yes No If yes, please list their name: Phone: Do you have any disease, condition, or problem not listed above that you think I should know about? Yes No Please Explain: NOTE: Both Doctor and Patient are encouraged to discuss all relevant patient health issues prior to treatment. 11. Financial Consent I understand that if I do not have dental insurance, I am responsible for payment in full at time of treatment. If I do have dental insurance, I am responsible for my estimated portion in full at time of treatment. No warranty or guarantee can be provided on the treatment. I acknowledge full responsibility for the payment of such services. I agree that no refund is due if the tooth is lost prematurely or if other complications occur. While the office will make best attempt to get accurate insurance benefit information, I understand that any balance due after insurance pays (due to: under estimation, having met insurance plan maximum for year or for procedures not covered by insurance, etc.) or for accounts for which insurance has not paid within 60 days of treatment, that this balance is my responsibility and is due in full at that time. A fee of $50 will be applicable for appointment no show and cancellation within 24 hours of appointment time. The following modes of payment are acceptable: cash, credit/debit card and check payable to “Westborough Dentistree”. There will be a $25 processing charge on returned check. I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form. Patient Name: Patient/Guardian Signature: Date: Acknowledgement of Privacy Practices My signature confirms that I have been informed of my rights to privacy regarding my protected health information, under the Health Insurance Portability & Accountability act of 1996 (HIPAA). I understand that this information can and will be used to: Provide and coordinate my treatment among a number of healthcare providers who may be involved in that treatment directly and indirectly. Obtain payment from third-party payers for my healthcare services. Conduct normal healthcare operations such as quality assessment and improvement activities. I have been informed of my dental provider's Notice of Privacy Practices containing a more complete description of the uses and disclosures of my protected health information. I have been given the right to review and receive a copy of such Notice of Privacy Practice. I understand that my dental provider has the right to change the Notice of Privacy Practices and that I may contact this office at the current address to obtain a current copy of the Notice of Privacy Practices. I understand that I may request, in writing, that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations and I understand that you are not required to agree to my requested restrictions, but if you do agree, then you are bound to abide by such restrictions. I have read & understand the above Initial: Patient Name: Relationship to Patient: Dependent family members also covered by this acknowledgement: Patient Signature: Clear Save Signature Date: Submit Form Please enable JavaScript for this form to work.
