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Patient registration 4

B O G D A N M A D U R O W I C Z , D . D . S .
PATIENT REGISTRATION
PLEASE PRINT
Date ___________________________
Patient Name _____________________________________________________________________ Date of Birth __________________________________
Last Name
First Name
Address _________________________________________________________ City __________________________ State ______ ZIP _________
❐ Home Phone Number ( ) ________________________ ❐ Cell ( ) ________________________ Fax ( ) _________________________
Please check which phone number would you like our office to use when contacting you with dental information or appointment reminder calls.
Do not call before ________ AM or after ________ PM E-Mail (Appointment Reminders) _________________________________________________
Dr. License # ________________________ Sex ❐ M ❐ F Age ________ ❐ Single ❐ Married ❐ Separated ❐ Divorced
Patient Employed by ___________________________________________ Occupation _______________________________________________________
Business Address ___________________________________________________________________ Business Phone ( ) ________________________
Spouse/Parent Name ________________________________________________________________________ Phone ( ) ________________________
Who is responsible for this account? __________________________________________________ Relationship to Patient _____________________
Whom may we thank for referring you? _______________________________________________________________________________________________
We would like to place a gift certificate on the referring patient account to thank them for sharing us with a friend or family members.
Social Security Number ______________________________________________ Required for insurance billing and credit applicants only. All information
acquired is kept within this office. All correspondence with personal information is shredded. Insurance claims are sent via secure lines. X-rays are
sent via e-mail or postal with consent.
PRIMARY DENTAL INSURANCE
Employee _______________________________________________________________________________ Date of Birth ____________________________
Employer _______________________________________________________________________________ ❐ Single Coverage ❐ Family Coverage
Dental Insurance Carrier ______________________________________________________________________________________________________________
Claims Address _________________________________________________ City __________________________ State ______ ZIP _________
Unit/Suite #
800 Number ( ) ________________________ Group ID# ________________________________ SS# or ID# _______________________________
SECONDARY DENTAL INSURANCE
Employee _______________________________________________________________________________ Date of Birth ____________________________
Employer _______________________________________________________________________________ ❐ Single Coverage ❐ Family Coverage
Dental Insurance Carrier ______________________________________________________________________________________________________________
Claims Address _________________________________________________ City __________________________ State ______ ZIP _________
Unit/Suite #
800 Number ( ) ________________________ Group ID# ________________________________ SS# or ID# _______________________________
71 8 N . C o a s t H i g h w ay 1 0 1 Le u ca d i a , CA 9 2 0 2 4 P 4 4 2 . 75 3 . 718 5 | w w w . E n c i n i ta s C o s m e t i c D e n t i s t ry . n e t DENTAL HISTORY
THE THOROUGHNESS OF THIS DENTAL HISTORY QUESTIONNAIRE IS DESIGNED FOR YOUR SAFETY.
COMPLETE ANSWERS WILL ASSIST US IN TREATING YOU WITH CONSIDERATION FOR YOUR INDIVIDUAL NEEDS.
Reason for today’s visit _______________________________________________________________________________________________________________________________
Former dentist _________________________________________________________________________________________________________________________________________
Phone ( ) ________________________________ Date of last dental care ______________________ Date of last dental x-rays _____________________
CHECK IF YOU HAVE/HAD ANY OF THE FOLLOWING
❐ Bad breath
❐ Dry mouth
❐ Bleeding gums
❐ Loose teeth or broken filings
❐ Clicking or popping jaw
❐ Periodontal treatment
❐ Food collecting between teeth
❐ Sores or growths in your mouth
❐ Are your teeth sensitive to
Hot or Cold? (Circle one)
❐ Do any of your teeth hurt biting down?
❐ Are your teeth sensitive eating sweets?
HOW OFTEN DO YOU BRUSH? ________________________________________ HOW OFTEN DO YOU FLOSS? _______________________________________
1. ARE YOU HAPPY WITH THE APPEARANCE OF YOUR TEETH? ❐ Yes ❐ No
2. IF UNHAPPY, WHAT CHANGE WOULD YOU MAKE? ____________________________________________________________________________________________
3. HAVE YOU EVER BLEACHED YOUR TEETH? ❐ Yes ❐ No
4. ARE YOU INTERESTED IN LEARNING ABOUT HOW COSMETIC DENTISTRY CAN BENEFIT YOU? ❐ Yes ❐ No
ASSIGNMENT AND RELEASE
I understand that I am financially responsible for all charges. Payment for procedures are due at the time of service unless other
arrangements have been made prior to completing procedures. I hereby authorize the doctor to release all information necessary to secure
the payment of benefits. Insurance benefits will be sent directly to the subscriber. I will be responsible for understanding my insurance
benefits and frequency limitations. I authorize the use of this signature on all my insurance submissions manual or electronic. I authorize the
doctor to share information with dental specialists, and staff members that are involved with my dental care. All information is confidential.
Signature _____________________________________________________________________________________________ Date _______________________________________
MINOR/CHILD CONSENT
I, being the parent or guardian of ___________________________________________________________ do hereby request and authorize the dental staff
to perform the necessary dental services for my child, including but not limited to x-rays, and administration of anesthetics which are
deemed advisable by the doctor, whether or not I am present at the actual appointment when the treatment is rendered.
Signature _____________________________________________________________________________________________ Date _______________________________________
MEDICAL HISTORY
THE THOROUGHNESS OF THIS MEDICAL HISTORY QUESTIONNAIRE IS DESIGNED FOR YOUR SAFETY.
COMPLETE ANSWERS WILL ASSIST US IN TREATING YOU WITH CONSIDERATION FOR YOUR INDIVIDUAL NEEDS.
Name of Primary Care Physician ___________________________________________________________________ Phone ( ) ________________________________
Additional Physician ________________________________________ Specialty __________________________ Phone ( ) ________________________________
1. DO YOU HAVE A CURRENT MEDICAL PROBLEM? ❐ Yes ❐ No
If yes, please describe _____________________________________________________________________________________________________________________________
2. ARE YOU CURRENTLY TAKING ANY MEDICATIONS? ❐ Yes ❐ No
If yes, please describe _____________________________________________________________________________________________________________________________
3. HAVE YOU EVER TAKEN A BIOSPHOSPHOMATE MEDICATION? (ie. Fosomax, Actonel, Zomeda, Aredia) ❐ Yes ❐ No
4. IF FEMALE, ARE YOU PREGNANT? IF SO, HOW FAR ALONG? __________ months
Please describe the use of any drugs or discuss in complete confidentiality with the doctor. The use of recreational drugs, such as cocaine, stimulants
and others may have a fatal interaction with local anesthetics or other common dental medications.
PLEASE INDICATE WHICH ONES
❐ Heart Medication
❐ Blood Pressure Medication
❐ Nitroglycerine
❐ Antibiotics
❐ Sedatives
❐ Tranquilizers
❐ Herbal Supplements
❐ Pain Medications
❐ Cortisone (steroids)
❐ Blood Thinners
❐ Birth Control Pills
❐ Vitamins
❐ Anti-anxiety
❐ Anti-depressant
❐ Other Medication
Name of Medication _______________________________________ Dosage _________________________ Purpose _______________________________________
__________________________________________________________________________________________________________________________________________________________ 5. ARE YOU ALLERGIC TO ANY MEDICINES/PRODUCTS OR HAVE YOU HAD ANY UNUSUAL REACTION TO ANY MEDICATIONS AND/OR
PRODUCTS? HAVE YOU BEEN TOLD NOT TO TAKE PARTICULAR MEDICATIONS?
If yes, please describe _____________________________________________________________________________________________________________________________
❐ Yes ❐ No Penicillin
❐ Yes ❐ No Tylenol
❐ Yes ❐ No Novocaine
❐ Yes ❐ No Erythromycin
❐ Yes ❐ No Ibuprofen
❐ Yes ❐ No Xylocaine
❐ Yes ❐ No Other Antibiotics
❐ Yes ❐ No Epinephrine
❐ Yes ❐ No Lidocaine
❐ Yes ❐ No Sulfa Drugs
❐ Yes ❐ No Carbonate
❐ Yes ❐ No Fluoride
❐ Yes ❐ No Latex
❐ Yes ❐ No Silica
Allergic Reaction ______________________________________________________ How long ago did you have the reaction? ______________________________
See reverse (Medical History continued)
MEDICAL HISTORY CONTINUED
6. CHECK ANY OF THE FOLLOWING THAT YOU HAVE HAD OR HAVE AT THE PRESENT
❐ Mitral Valve Prolapse
❐ Liver Disease
❐ Arthritis
FOR DOCTOR’S USE __________________________
❐ Artificial Joint (Prosthesis)
❐ Hemophilia
❐ Diabetes
__________________________________________________ __________________________________________________ ❐ Heart Failure/Attack
❐ Thyroid Disease
❐ Blood Transfusion
__________________________________________________ ❐ Prosthetic Heart Valve
❐ Kidney Disease
❐ Cold Sores
__________________________________________________ ❐ Angina
❐ Head/Neck Injury
❐ Cancer/Chemotherapy
__________________________________________________ ❐ High Blood Pressure
❐ Back Injury
❐ Osteoporosis
__________________________________________________ __________________________________________________ ❐ HIV positive/AIDS
❐ Hepatitis (A, B or C)
__________________________________________________ 7. PATIENT HABITS
❐ Yes ❐ No Pipe/Cigar/Cigarette Smoking
❐ Yes ❐ No Do you Snore?
❐ Yes ❐ No Tongue Thrusting
❐ Yes ❐ No Smokeless Tobacco Use
❐ Yes ❐ No Sleep Apnea
❐ Yes ❐ No Mouth Breathing
❐ Yes ❐ No Nail Biting
❐ Yes ❐ No Treated for TMJ
❐ Yes ❐ No Substance Abuse
❐ Yes ❐ No Gum Chewing
❐ Yes ❐ No Anorexia /Bulimia
❐ Yes ❐ No Headaches
❐ Yes ❐ No Teeth Grinding/Clenching
❐ Yes ❐ No Cheek Biting
❐ Yes ❐ No Do you have difficulty opening your mouth wide?
❐ Yes ❐ No Have you had Orthodontic Treatment?
❐ Yes ❐ No Do you wear a retainer?
❐ Yes ❐ No Do your joints click when you chew?
❐ Yes ❐ No Have you had Nitrous Sedation with dentistry?
8. HAVE YOU HAD A BAD DENTAL EXPERIENCE IN THE PAST? ❐ Yes ❐ No
If yes, please describe _____________________________________________________________________________________________________________________________
9. ARE YOU CURRENTLY BEING TREATED FOR A MEDICAL/DENTAL CONDITION? ❐ Yes ❐ No
If yes, please describe _____________________________________________________________________________________________________________________________
10. IS THERE ANYTHING ELSE ABOUT YOUR MEDICAL/DENTAL HISTORY WE SHOULD BE AWARE OF? ❐ Yes ❐ No
If yes, please describe _____________________________________________________________________________________________________________________________
I hereby grant authority to the dentist(s) in charge of the patient whose name appears on this health history form to administer any treatment and
to administer such x-rays, anesthetics or sedative/ and to perform such operations as may be deemed necessary or advisable in the diagnosis and
treatment of this patient.
Signature _____________________________________________________________________________________________ Date _______________________________________
Relationship (if patient is a minor or physically or mentally disabled) ____________________________ Date _______________________________________
IF MINOR,
Guardian Signature __________________________________________________________________________________ Date _______________________________________
B O G D A N M A D U R O W I C Z , D . D . S .
FINANCIAL AGREEMENT
FOR THE OFFICE OF
BOGDAN R. MADUROWICZ, DDS
This agreement is to inform you of your financial obligation to our practice. We are committed to providing you with the most comprehensive dental care using only the highest quality materials and technology available in the market today. We are also committed to providing you with up-to-date information and educational tools so that you may fully participate in maintaining optimum oral health. This financial agreement is intended to facilitate our ability to provide excellent service to you while minimizing our administrative costs.
All charges you incur are your responsibility regardless of your insurance coverage. We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your insurance company. Your insurance policy is an agreement between you, your employer, and the insurance company. Our practice is not a party to that agreement. As a courtesy to you, we will help you process all your insurance claims. In order for our practice to file your insurance claim properly you will be asked for up-to-date insurance information. All insurance benefits will be assigned to you. If any insurance benefit checks are accidentally sent to us and your account balance is zero, we will refund you the amount within the week it is received. We will process all your insurance claims and your dental benefits will be mailed directly to you.
Payments for services rendered are due at the time treatment is provided. For your convenience, our practice accepts MasterCard, Visa, American Express, and Discover, as well as cash and personal checks. Third party, extended payment financing is available upon request and credit approval. Other payment arrangements will be considered on a “need basis” and should be discussed with the front office prior to any services. Returned checks and unpaid balances older than 60 days will be subject to a collection fee of $50.00 as well as possible interest charges of 18% per annum. 90-day past due accounts are sent to a collection agency.
Time is a very valuable asset that we continually respect and expect the same in return. Please be informed our cancellation fee for missed and rescheduled appointments without a 48 hour notice is $50.00 per hygiene hour and 15% of the procedure fee with Dr. Madurowicz. Emergencies will be understood. Please do not hesitate to ask if you have any questions regarding this financial agreement. We are committed to providing you with an excellent experience in dental care.
Print Name of Patient ___________________________________________________ Date ______________________ Signature of Patient or Responsible Party ____________________________________________________________ 71 8 N . C o a s t H i g h w ay 1 0 1 Le u ca d i a , CA 9 2 0 2 4 P 4 4 2 . 75 3 . 718 5 | w w w . E n c i n i ta s C o s m e t i c D e n t i s t ry . n e t

Source: http://www.encinitascosmeticdentistry.net/NewPatientForms.pdf