Patient Registration

GETTING TO KNOW YOU

Is another member of your family or relative a patient in our office?*

Whom?

First & Last Name

Emergency Contact*

Phone*

Address

Street Address Address Line 2 City State ZIP Code

HEALTH HISTORY

1. Are you having pain or discomfort at this time?*

YES
NO

2. Do you feel very nervous about having dental treatment?*

YES
NO

3. Have you ever had a bad experience in a dental office?*

YES
NO

4. Have you been under the care of a physician during the past 2 years?*

YES
NO

Physician's Name

Physician's Address

5. Are you currently taking any medications, drubs, or substances?*

YES
NO

Please list:

Click the plus sign on the right to add more boxes.

6. Are you allergic to any medications or substances?*

YES
NO

Please list:

Click the plus sign on the right to add more boxes.

Tick/Click any of the following which you have had or have at present:

Are you pregnant?

If pregnant what month?

Terms

The above information is accurate and complete to the best of my knowledge and is only for use in my treatment, billing, and processing of insurance for benefits for which I am entitled.

I will not hold my dentist or any member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form.

I understand my signature will be used as a “signature on file” for insurance processing.

I understand that responsibility for payment for Dental Services provided in this office for myself or my dependents is mine, due and payable at the time services are rendered unless financial arrangements have been made.

I further agree that a 1 ½% finance charge (18% annually) will be added to any balance over 60 days. In the event of default I promise to pay legal interest on the indebtedness, together with such collection costs and reasonable attorney fees as may be required to effect collection of this note.

****There will be a $25 charge for all appointments cancelled without 24 hours notice****

The undersigned hereby authorizes Doctor to take x-rays, study models, photographs, or any other diagnostic aids deemed appropriate by Doctor to make a thorough diagnosis of the patient’s dental needs. I also authorize Doctor to perform any and all forms of treatment, medication, and therapy, that may be indicated in connection with (Name of Patient)

Check both boxes to accept terms.*

Yes, I understand and accept terms.
Yes, I undestand I will received a copy of this office’s Notice of Privacy Practices at the office

Type Initials Below To Confirm Acceptance:*

Email

This field is for validation purposes and should be left unchanged.

DrJenniferTRose.com

Current Patients:

New Patient Registration:

Your privacy is assured. We do not rent, sell, or share your information with anyone that is not required by law.

Step 1 of 3

Patient Information

Dental Insurance Information

PERSON FINANCIALLY RESPONSIBLE FOR ACCOUNT

GETTING TO KNOW YOU

HEALTH HISTORY

Terms