Patient Sign-in

Patient Registration Form

Patient Sign-in
New patient Registration
Medical History
Medical history
Dental History
Dental history

Patient Registration( * mandatory to fill )

Is the Patient Under 18(Minor)?
Yes
No

Guardian Information

How do we contact you?( * mandatory to fill )

Who do we contact in case of an emergency?( * mandatory to fill )

Please select below

Are You Married?
Yes No
Are You Employed?
Yes No
Do You Have Primary Insurance?
Yes No
Do You Have Secondary Insurance?
Yes No
I have read the above choices

Professional Information

Spouse Information( * mandatory to fill )

Primary Insurance Information( * mandatory to fill )

POLICY HOLDER : SELF OTHER
Dental Coverage: Yes No Unknown
Medical Coverage: Yes No Unknown
Orthodontic Coverage: Yes No Unknown
SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

Secondary Insurance Information( * mandatory to fill )

POLICY HOLDER : SELF OTHER
Dental Coverage: Yes No Unknown
Medical Coverage: Yes No Unknown
Orthodontic Coverage: Yes No Unknown
SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

Responsible Person for the Account( * mandatory to fill )

SELF OTHER

Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

(All questions are required * )

Are you under a physicians care now?
Yes
No
Have you ever had a serious head or neck injury?
Yes
No
Are you taking any medication, pills or drugs?
Yes
No
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
Yes
No
Do you take, or have you taken, Phen-fen or Redux?
Yes
No
Have you ever been hospitalized or had a major operation?
Yes
No
Are you on a special diet?
Yes
No
Do you use tobacco?
Yes
No
I have answered all the above questions

Medical History

Are you a woman?
Yes
No
Are you allergic to any of the following?
Do you use controlled substances?
Yes
No
I have answered all the above questions

Medical History

Do you or have you experienced the following?

AIDS/HIV Positive
Yes
No
Alzheimers disease
Yes
No
Anaphylaxis
Yes
No
Anemia
Yes
No
Angina
Yes
No
Arthritis/Gout
Yes
No
Artificial Heart Valves
Yes
No
Artificial Bones/Joints
Yes
No
Asthma
Yes
No
Blood Disease
Yes
No
Blood Transfusion
Yes
No
Breathing Problems
Yes
No
Bruise Easily
Yes
No
Cancer
Yes
No
Chemotheropy
Yes
No
Chest Pain
Yes
No
Cold sores / Fever blisters
Yes
No
Congenital heart disorder
Yes
No
Convulsion
Yes
No
Cortisone medicine
Yes
No
Diabetes
Yes
No
Difficulty Breathing
Yes
No
Drug Addiction
Yes
No
Easily Winded
Yes
No
Emphysema
Yes
No
Epilepsy or Seizures
Yes
No
Excessive Bleeding
Yes
No
Excessive Thirst
Yes
No
Fainting spells / Dizziness
Yes
No
Frequent Cough
Yes
No
Frequent Diarrhea
Yes
No
Frequent Headaches
Yes
No
Genital Herpes
Yes
No
Glaucoma
Yes
No
Hay Fever
Yes
No
Heart Attack / Failure
Yes
No
Heart Murmer
Yes
No
Heart Pacemaker
Yes
No
Heart Trouble / Desease
Yes
No
Hemophilea
Yes
No
Hepatitis A
Yes
No
Hepatitis B or C
Yes
No
Herpes
Yes
No
High Blood Pressure
Yes
No
High Cholesterol
Yes
No
Hives or Rash
Yes
No
Hypoglycemia
Yes
No
Irregular Heartbeat
Yes
No
Kidney Problem
Yes
No
Leukemia
Yes
No
Liver Disease
Yes
No
Low Blood Pressure
Yes
No
Lung diseases
Yes
No
Mitral Value prolapse
Yes
No
Osteoporosis
Yes
No
Pain in Jaw Joints
Yes
No
Parathyroid Disease
Yes
No
Psychiatric Care
Yes
No
Radiation Treatments
Yes
No
Recent Weight Loss
Yes
No
Renal Dialysis
Yes
No
Rheumatic Fever
Yes
No
Rheumatism
Yes
No
Scarlet Fever
Yes
No
Shingles
Yes
No
Sickle Cell Disease
Yes
No
Sinus Trouble
Yes
No
Spina Bifida
Yes
No
Stomach/Intestinal Disease
Yes
No
Stroke
Yes
No
Swelling of Limbs
Yes
No
Thyroid Disease
Yes
No
Tonsillitis
Yes
No
Tuberculosis
Yes
No
Tumors or Growths
Yes
No
Ulcers
Yes
No
Venereal Disease
Yes
No
Yellow Jaundice
Yes
No
Have you ever had serious illnesses not listed?
Yes
No
I have answered all the above questions

What is the reason for your visit?
Are you currently in pain?
Yes
No
Do you require antibiotics before dental treatment?
Yes
No
Have you experienced problems associated with any previous dental work?
Yes
No
Do you now or have you ever experienced pain/ discomfort in your jaw joints (TMJ/TMD)?
Yes
No
Do you floss daily?
Yes
No
Do you use anything in addition to your brush and floss ?
Yes
No
Would you like whiter teeth?
Yes
No
Do your gums ever Itch?
Yes
No
Do you brush daily?
Yes
No
Would you like fresher breath?
Yes
No

Do your gums ever bleed?
Yes
No
Have you ever had Periodontal disease?
Yes
No
Do you have mobility in teeth ?
Yes
No
Do you still have wisdom teeth?
Yes
No
Your current dental health is
Good
Fair
Poor
Type of bristles on your toothbrush?
Hard
Medium
Soft
Are Your Teeth Sensitive to?
Heat
Cold
Other
Previous Dental Practice name?
Last visit to a Dental Office?
Are you happy with the way your smile looks?
Yes
No

Treatment Authorization

The information on this page is correct to the best of my knowledge. I authorize and give consent to perform dental services agreed between doctor and patient and/or parent or guardian to be necessary or advisable including the use of local anesthesia and other medication as indicated. I certify to the above statements regarding my medical condition.

SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

Office Financial Policy

Payment is expected at time of service. We will accept cash, check, or credit card. Checks accepted with valid driver’s license only.

We accept insurance. We will file your claims at no charge. It is the patient’s responsibility to provide us with current insurance information.

If any payment from an insurance company becomes 30 days past due, you will be immediately billed for the entire balance.

We will file pre-treatment estimates, AT YOUR REQUEST ONLY. Please be aware that some insurance companies may not honor a pre-treatment estimate or may alter it. In all cases it may delay important dental care.

Not all services are covered by insurance. In the event your insurance plan determines a service to be “not covered”, you will be responsible for the complete charge. Our staff can never guarantee your eligibility and coverage.

Insurance limitations and regulations vary with all insurance plans. Therefore, if your insurance plan denies a service, you will be responsible for the complete charge. We do not base your treatment plan on what your insurance plan covers or doesn’t cover. We are working for you, not the insurance company.

Past due accounts may be turned over to a collection agency. Any fees incurred due to this, will be added to the outstanding balance. This may include late fees, collection agency fees, court fees etc.

SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

Missed Appointment Policy

Due to the high number of patients requiring dental care, waiting times for appointments can be long. Because of this, we enforce a missed appointment policy to ensure that other patients receive care in a timely manner. Missed appointments and appointments cancelled without 24-hour notice are subject to a cancellation fee.

Recieve Appointment Reminders Via Email And Text

Please check a source in which you would like to recieve appointment reminders.*

Email  
Text Message  
Both Email and Text Message

We use this information to provide you with excellent treatment. We may disclose Patient Health Information (PHI) to third parties that perform services for LuxeSmile Dentistry in the administration of your benefits in accordance with HIPAA. These parties are required by law to sign a contract agreeing to protect the confidentiality of your PHI. Your PHI may be disclosed to an affiliate that performs services for LuxeSmile Dentistry in the administration of your benefits. Our affiliates do not sell, share or rent our users’ personally identifiable information unless required by law, do not send and e-mail or other communications without user permission, and do not send spam.

SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )
Thank you for visiting LuxeSmile Dentistry. We want your visit to be pleasant and comfortable.Please help us by completing this form
Patient Information

Personal Details

Title: First Name: Last Name: Date Of Birth: Social Security Number: Gender: Marital Status:
Is the Patient Under 18( Miner )? Yes No

Guardian Details

First Name: Last Name: Date Of Birth: Phone Number: Relation to Patient:

Address

Street Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Email Address: Driver's License:

Emergency Contact Information

Name: Relation: Home Phone: Work Phone: Address: City: State: Zip Code:

Professional Information

Employer Name: Position: Employer Address: City: State: Zip Code:
Are You Employed? Yes No

Spouse Information

Spouse Name: Date Of Birth Phone Number: Employer:
Are You Married? Yes No

Primary Insurance Information

Dental Coverage Yes No Unknown
Medical Coverage Yes No Unknown
Orthodontic Coverage Yes No Unknown
Insurance Co. Name: Phone Number: Group (Plan , Local , Policy): Insurance Co.Address: City: State: Zip Code: Insured Name: Insured Social Security: Insured Birth Date: Relation: Insured Employer: Employer's Address: City: State: Zip Code:
Do You have Primary Insurance? Yes No

Secondary Insurance Information

Dental Coverage Yes No Unknown
Medical Coverage Yes No Unknown
Orthodontic Coverage Yes No Unknown
Insurance Co. Name: Phone Number: Group (Plan , Local , Policy): Insurance Co.Address: City: State: Zip Code: Insured Name: Insured Social Security: Insured Birth Date: Relation: Relation: Insured Employer: Employer's Address: City: State: Zip Code:
Do You have Secondary Insurance? Yes No

Responsible Person for Account

Name: Relation Home Phone: Social Security number: Address: City: State: Zip: Employer: Work Phone: Billing Address: City: State: Zip:
Medical History
Are you under a physicians care now?
Yes
No
Details:
Have you ever had a serious head or neck injury?
Yes
No
Details:
Are you taking any medication, pills or drugs?
Yes
No
Details:
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
Yes
No
Details:
Do you take, or have you taken, Phen-fen or Redux?
Yes
No
Details:
Have you ever been hospitalized or had a major operation?
Yes
No
Details:
Are you on a special diet?
Yes
No
Do you use tobacco?
Yes
No
Are you a woman?
Yes
No
Pregnant/trying to get pregnant Nursing Taking oral contraceptives None
Are you allergic to any of the following?
Aspirin Penicillin Codeine Acrylic
Metal Latex Sulfa drugs Local anesthetics
Others
Details:
Do you use controlled substances?
Yes
No
Details:
Do you or Have you experienced the following ?
AIDS/HIV Positive Alzheimers disease Anaphylaxis
Anemia Angina Arthritis/Gout
Artificial Heart Valves Artificial Bones/Joints Asthma
Blood Disease Blood Transfusion Breathing Problems
Bruise Easily Cancer Chemotheropy
Chest Pain Cold sores / Fever blisters Congenital heart disorder
Convulsion Cortisone medicine Diabetes
Difficulty Breathing Drug Addiction Easily Winded
Emphysema Epilepsy or Seizures Excessive Bleeding
Excessive Thirst Fainting spells / Dizziness Frequent Cough
Frequent Diarrhea Frequent Headaches Genital Herpes
Glaucoma Hay Fever Heart Attack / Failure
Heart Murmer Heart Trouble / Desease Hemophilea
Hepatitis A Hepatitis B or C Herpes
High Blood Pressure High Cholesterol Hives or Rash
Hypoglycemia Irregular Heartbeat Kidney Problem
Leukemia Liver Disease Low Blood Pressure
Lung diseases Mitral Value prolapse Osteoporosis
Pain in Jaw Joints Parathyroid Disease Psychiatric Care
Radiation Treatments Recent Weight Loss Renal Dialysis
Rheumatic Fever Rheumatism Scarlet Fever
Shingles Sickle Cell Disease Sinus Trouble
Spina Bifida Stomach/Intestinal Disease Stroke
Swelling of Limbs Thyroid Disease Tonsillitis
Tuberculosis Tumors or Growths Ulcers
Venereal Disease Yellow Jaundice
Have you ever had serious illnesses not listed?
Yes
No
Details:
Dental History
Purpose Of Visit
Are you currently in pain?
Yes
No
Do you require antibiotics before dental treatment?
Yes
No
Do you now or have you ever experienced pain/ discomfort in your jaw joints (TMJ/TMD)?
Yes
No
Do you floss daily?
Yes
No
Do you use anything in addition to your brush and floss?
Yes
No
Details:
Would you like whiter teeth?
Yes
No
Do your gums ever itch?
Yes
No
Do you brush daily?
Yes
No
Would you like fresher breath?
Yes
No
Do your gums ever bleed?
Yes
No
Have you ever had Periodontal disease?
Yes
No
Do you have mobility in teeth?
Yes
No
Do you still have wisdom teeth?
Yes
No
Details:
Your current dental health is
Good
Fair
Poor
Type of bristles on your toothbrush?
Hard
Medium
Soft
Are your teeth sensitive to?
Heat
Cold
Other
Current/Previous Dental: Last visit:
Are you happy with the way your smile looks?
Yes
No
Details:

Treatment Authorization

The information on this page is correct to the best of my knowledge. I authorize and give consent to perform dental services agreed between doctor and patient and/or parent or guardian to be necessary or advisable including the use of local anesthesia and other medication as indicated. I certify to the above statements regarding my medical condition.

The information on this page is correct to the best of my knowledge.
 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

Office Financial Policy

Payment is expected at time of service. We will accept cash, check, or credit card. Checks accepted with valid driver’s license only.

We accept insurance. We will file your claims at no charge. It is the patient’s responsibility to provide us with current insurance information.

If any payment from an insurance company becomes 30 days past due, you will be immediately billed for the entire balance.

We will file pre-treatment estimates, AT YOUR REQUEST ONLY. Please be aware that some insurance companies may not honor a pre-treatment estimate or may alter it. In all cases it may delay important dental care.

Not all services are covered by insurance. In the event your insurance plan determines a service to be “not covered”, you will be responsible for the complete charge. Our staff can never guarantee your eligibility and coverage.

Insurance limitations and regulations vary with all insurance plans. Therefore, if your insurance plan denies a service, you will be responsible for the complete charge. We do not base your treatment plan on what your insurance plan covers or doesn’t cover. We are working for you, not the insurance company.

Past due accounts may be turned over to a collection agency. Any fees incurred due to this, will be added to the outstanding balance. This may include late fees, collection agency fees, court fees etc.

 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

Missed Appointment Policy

Due to the high number of patients requiring dental care, waiting times for appointments can be long. Because of this, we enforce a missed appointment policy to ensure that other patients receive care in a timely manner. Missed appointments and appointments cancelled without 24-hour notice are subject to a cancellation fee.

Recieving Appointment Reminders Via Email and Text

Please check a source in which you would like to recieve appointment reminders.

Email
Text Message
Both Email and Text Message
Email Address(if applicable)
Cell Phone(if applicable)

We use this information to provide you with excellent treatment. We may disclose Patient Health Information (PHI) to third parties that perform services for LuxeSmile Dentistry in the administration of your benefits in accordance with HIPAA. These parties are required by law to sign a contract agreeing to protect the confidentiality of your PHI. Your PHI may be disclosed to an affiliate that performs services for LuxeSmile Dentistry in the administration of your benefits. Our affiliates do not sell, share or rent our users’ personally identifiable information unless required by law, do not send and e-mail or other communications without user permission, and do not send spam.

 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

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