Patient Sign-in

Patient Registration Form

Patient Sign-in
New patient Registration
Medical History
Medical history

Patient Registration( * mandatory to fill )

Is Patient Responsible Party ?
Yes
No
Is Patient Policy Holder ?
Yes
No

Responsible Party (if someone other than the patient)

Patient Information( * mandatory to fill )

I would like to receive correspondences via e-mail.

Please select below

Is Responsible Party is also a Policy Holder for Patient?
Yes No
Primary Insurance Policy Holder?
Yes No
Secondary Insurance Policy Holder?
Yes No
I have read the above choices

Section 2

Employment Status:
Full Time Part Time Retired
Student Status:
Full Time Part Time

Section 3

Primary Insurance Information( * mandatory to fill )

POLICY HOLDER : SELF OTHER
SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

Secondary Insurance Information( * mandatory to fill )

POLICY HOLDER : SELF OTHER
SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

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 have, or have you had, any of 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
Chemotherapy
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 Murmur
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 Valve 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
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

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.

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.

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.

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 of 50$.

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 Dentistry by Dr.Doshi 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 Dentistry by Dr.Doshi 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 Dentistry By Dr.Doshi. We want your visit to be pleasant and comfortable.Please help us by completing this form
PATIENT REGISTRATION
First Name:                          Last Name:                          Middle Initial:            
Patient Is:
Policy Holder?
Responsible Party?
Preferred Name:            
Responsible Party (if someone other than the patient)
First Name:                          Last Name:                          Middle Initial:            
Address:            
City:       State:       Zip Code:    Pager:      
Home Phone:       Work Phone:       Ext:     Cellular:      
Birth Date:             Soc Sec:             Drivers Lic:            
Responsible Party is also a Policy Holder for Patient? Primary Insurance Policy Holder? Secondary Insurance Policy Holder?
 
Patient Information
Address:            
City:       State:       Zip Code:       Pager:      
Home Phone:       Work Phone:       Ext:     Cellular:      
Sex:             Marital Status:            
Birth Date:             Soc.Sec:             Drivers Lic:            
Email Address:             I would like to receive correspondences via e-mail
 
Section 2
Employment Status? Full Time Part Time Retired
Student Status? Full Time Part Time
Medicaid ID:      
Employer ID:      
Carrier ID:      
Pref. Dentist:      
Pref. Pharmacy:      
Pref. Hyg.:      
Section 3
Referred By:      
Previous Dentist:      
Emergency Contact:      
Emergency Contact #:      
 
Primary Insurance Information
Name of Insured:             Relationship to Insured:            
Insured Soc. Sec:             Insured Birth Date:            
Employer:      
Address:      
City:      
State:      
Zip Code:      
Rem. Benefits:       Rem. Deduct:      
Ins. Company:      
Address:      
City:      
State:      
Zip Code:      
       
 
Secondary Insurance Information
Name of Insured:             Relationship to Insured:            
Insured Soc. Sec:             Insured Birth Date:            
Employer:      
Address:      
City:      
State:      
Zip Code:      
Rem. Benefits: Rem. Deduct:
Ins. Company:      
Address:      
City:      
State:      
Zip Code:      
       
MEDICAL HISTORY
PATIENT NAME:                  Birth Date:              

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.

Are you under a physician's care now?
Yes
No
If yes, please explain:
Have you ever been hospitalized or had a major operation?
Yes
No
If yes, please explain:
Have you ever had a serious head or neck injury?
Yes
No
If yes, please explain:
Are you taking any medication, pills or drugs?
Yes
No
If yes, please explain:
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:
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 Taking oral contraceptives Nursing
Are you allergic to any of the following?
Aspirin Penicillin Codeine Local anesthetics
Acrylic Metal Latex Sulfa drugs
Other If yes, please explain:
Do you use controlled substances?
Yes
No
Details:
Do you have, or have you had, any of 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 Chemotherapy 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 Murmur 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 Valve 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
Comments:

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

 

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.

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.

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.

 
 
 
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 of $50.

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 Dentistry by Dr.Doshi 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 Dentistry by Dr.Doshi 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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