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

Is this parent/legal guardian currently a patient in our office?
Yes No

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

Home Work Cell

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's Information( * mandatory to fill )

Do you have children and grand children?If so,please list their names and ages

Primary Carrier( * mandatory to fill )

POLICY HOLDER : SELF OTHER
Is insured a patient in our practice?
Yes No
SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

Secondary Carrier( * mandatory to fill )

POLICY HOLDER : SELF OTHER
Is insured a patient in our practice?
Yes No
SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

Person Financially Responsible for 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 * )

Have you been hospitalized or under the care of a medical doctor during the past two years?
Yes
No
Have you taken any medication or drugs in the past two years?
Yes
No
Are you currently taking any medications or drugs?(Including regular doses of aspirin or over-the-counter medicines)
Yes
No
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
Yes
No
Do you use tobacco?
Yes
No
I have answered all the above questions

Medical History

Are you a woman?
Yes
No


Do you require antibiotics before dental treatment ?
Yes
No
Are you aware of having an allergic (or adverse) reaction to any of the following?
I have answered all the above questions

Medical History

Indicate which of the following you have had or have at present?

AIDS/HIV
Yes
No
Alcohol/Drug Addiction
Yes
No
Alzheimers disease
Yes
No
Allergies or Hives
Yes
No
Anemia
Yes
No
Arthritis/Rheumatism
Yes
No
Artificial Heart Valve
Yes
No
Artificial Bones/Joints
Yes
No
Asthma
Yes
No
Blood Disease
Yes
No
Blood Transfusion
Yes
No
Bruise Easily
Yes
No
Cancer/Chemotherapy
Yes
No
Chest Pain
Yes
No
Cold sores / Herpes
Yes
No
Colitis
Yes
No
Contact Lenses
Yes
No
Cortisone medicine
Yes
No
Diabetes
Yes
No
Diet(Special/Restricted)
Yes
No
Difficulty Breathing
Yes
No
Emphysema
Yes
No
Epilepsy or Seizures
Yes
No
Fainting or Dizzy Spells
Yes
No
Frequent Headaches
Yes
No
Glaucoma
Yes
No
Hay Fever
Yes
No
Heart(Surgery,disease,Attack)
Yes
No
Heart Murmur
Yes
No
Heart Pacemaker
Yes
No
Hemophilea/Abnormal Bleeding
Yes
No
Hepatitis A B C
Yes
No
High or Low Blood Pressure
Yes
No
Hospitalized For Any Reason
Yes
No
Jaundice
Yes
No
Kidney Trouble
Yes
No
Liver Disease
Yes
No
Lupus
Yes
No
Mitral Valve Prolapse
Yes
No
Nervousness/Anxiety
Yes
No
Neurological Disorders
Yes
No
Osteoporosis
Yes
No
Psychiatric/Psychological Care
Yes
No
Radiation Therapy
Yes
No
Rheumatic/Scarlet Fever
Yes
No
Shingles/Chicken Pox
Yes
No
Sickle Cell Disease/Traits
Yes
No
Sinus Trouble
Yes
No
Snoring / Sleep Apnea
Yes
No
Stomach Problems/Ulcers
Yes
No
Stroke
Yes
No
Swollen ankles
Yes
No
Thyroid Problems
Yes
No
Tuberculosis(TB)
Yes
No
Tumors
Yes
No
Venereal Disease/STD
Yes
No
Please list any serious medical condition(s) that you have ever had not listed above?
I have answered all the above questions

Reason for Today's Visit?
Are you currently in pain?
Yes
No
Do you have any dental problems now?
Yes
No
Have you ever had trouble with a previous dental treatment?
Yes
No
Level of anxiety about seeing the dentist (1 (least) and 5 (most))
What type of bristles do you use?
Hard
Medium
Soft
Do your gums ever bleed?
Yes
No
Have you noticed any mouth odors or bad tastes?
Yes
No
Are you sensitive to heat / cold?
Yes
No
Do you bite your lips or cheeks frequently?
Yes
No
Do you have frequent headaches?
Yes
No
Do you clench or grind your teeth?
Yes
No
Do you feel rested when you wake?
Yes
No

Have you ever had:

Periodontal disease/gum treatment?
Yes
No
Discomfort in your jaw joints (TMJ/TMD)?
Yes
No
Orthodontics treatment (Braces) ?
Yes
No
Your teeth ground or bite adjusted?
Yes
No
Oral surgery?
Yes
No
Serious injury to the mouth or head?
Yes
No
A bite plate or mouth guard?
Yes
No
If yes to any of the previous questions, please describe
Is there anything else about your past dental treatment(s) that you would like us to know?

Smile Analysis

1. Do you love the way your smile looks?
Yes
No
2. Do you feel comfortable showing your teeth when you laugh or smile?
Yes
No
3. If you could change anything about your smile,it would be(check all that apply):
4. Do you have(check all that apply):
5. In your line of work or lifestyle, do you(check all that apply):
6. If you had a smile makeover do you think you'd feel?(check all that apply):

We'd like to know more about you so we can server you better


7. Do you have any special dates or upcoming events you'd like us to remember?(weddings,graduations, etc.)
8. What are your favorite hobbies or activities?
9. Is there anything else that you want our office to know about you that will help us to serve you better?

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 48 business hours notice are subject to a cancellation fee of $50 per appointment hour.

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

RECEIVING APPOINTMENT REMINDERS VIA EMAIL AND TEXT

Please check a source in which you would like to receive 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 Judy L.Disanti, DMD and Associates 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 Judy L.Disanti, DMD and Associates 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 Judy L.Disanti, DMD and Associates. We want your visit to be pleasant and comfortable.Please help us by completing this form
Today's date:
Patient Information

Personal Details

Title:   First Name:   Middle Initial:   Last Name:  
Nick Name:
Date Of Birth:   Social Security Number:   Gender:   Marital Status:  

Whom may we thank for referring you?
How did you hear about our office?  
Is the Patient Under 18( Minor )? Yes No
 

Guardian Details

First Name:   Relation to Patient:   Is this parent/legal guardian currently a patient in our office?  

Child Details

School: Grade:

Address

Street Address:   City:   State:   Zip:
Home Phone:   Cell Phone:  
Work Phone: Email Address:   Primary Contact Number:

Professional Information

Employer Name: Occupation:
Are You Employed? Yes No

Spouse's Information

Spouse's Name: Spouse's Employer:
Do you have children and grand children?If so,please list their names and ages:
Are You Married? Yes No

Primary Carrier

Insurance Co. Name: Insurance Co. Phone:
Group No. (Plan or Policy No.): Insured's I.D.no
Insurance Co.Address: City: State: Zip Code:
Insured's Name: Insured's Social Security:
Insured's Birth Date: Relation: Insured's Employer Name:
Is insured a patient in our practice?
Do You have Primary Insurance? Yes No

Secondary Carrier

Insurance Co. Name: Insurance Co. Phone:
Group No. (Plan or Policy No.): Insured's I.D.no
Insurance Co.Address: City: State: Zip Code:
Insured's Name: Insured's Social Security:
Insured's Birth Date: Relation: Insured's Employer Name:
Is insured a patient in our practice?
Do You have Secondary Insurance? Yes No

Person Financially Responsible for Account

Name: Relation Cell Phone:

Social Security number: Date Of Birth:
Employer: Work Phone: Address:
City: State: Zip:
Medical History
Have you been hospitalized or under the care of a medical doctor during the past two years?
Yes
No
If yes,for what?
Hospital or Physician's Name:
Phone:
Hospital or Physician's City:
State:
Have you taken any medication or drugs in the past two years?
Yes
No
Are you currently taking any medications or drugs?(Including regular doses of aspirin or over-the-counter medicines)
Yes
No
If yes,please list names only:
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
Yes
No
If so,how long ago?
Do you use tobacco?
Yes
No
Are you a woman?
Yes
No
Are you pregnant or think you may be pregnant? Are you nursing?
Are you taking birth control pills? Are you trying to get pregnant?

Do you require antibiotics before dental treatment ?
Yes
No
Are you aware of having an allergic (or adverse) reaction to any of the following?
Acrylic Aspirin Penicillin Codeine
Jewelry/Metals Latex Sulfa drugs Anesthetics(i.e. Novocaine)
Erythromycin Sedatives Tetracycline
Other Antibiotics
list:
Indicate which of the following you have had or have at present?
AIDS/HIV Yes No Alcohol/Drug Addiction Yes No
Alzheimers disease Yes No Allergies or Hives Yes No
Anemia Yes No Arthritis/Rheumatism Yes No
Artificial Heart Valve Yes No Artificial Bones/Joints Yes No
Asthma Yes No Blood Disease Yes No
Blood Transfusion Yes No Bruise Easily Yes No
Cancer/Chemotherapy Yes No Chest Pain Yes No
Cold sores / Herpes Yes No Colitis Yes No
Contact Lenses Yes No Cortisone medicine Yes No
Diabetes Yes No Diet(Special/Restricted) Yes No
Difficulty Breathing Yes No Emphysema Yes No
Epilepsy or Seizures Yes No Fainting or Dizzy Spells Yes No
Frequent Headaches Yes No Glaucoma Yes No
Hay Fever Yes No Heart(Surgery,disease,Attack) Yes No
Heart Murmur Yes No Heart Pacemaker Yes No
Hemophilea/Abnormal Bleeding Yes No Hepatitis A B C Yes No
High or Low Blood Pressure Yes No Hospitalized For Any Reason Yes No
Jaundice Yes No Kidney Trouble Yes No
Liver Disease Yes No Lupus Yes No
Mitral Valve Prolapse Yes No Nervousness/Anxiety Yes No
Neurological Disorders Yes No Osteoporosis Yes No
Psychiatric/Psychological Care Yes No Radiation Therapy Yes No
Rheumatic/Scarlet Fever Yes No Shingles/Chicken Pox Yes No
Sickle Cell Disease/Traits Yes No Sinus Trouble Yes No
Snoring / Sleep Apnea Yes No Stomach Problems/Ulcers Yes No
Stroke Yes No Swollen ankles Yes No
Thyroid Problems Yes No Tuberculosis(TB) Yes No
Tumors Yes No Venereal Disease/STD Yes No
Please list any serious medical condition(s) that you have ever had not listed above?
Dental History
Reason for Today's Visit?
Are you currently in pain?
Yes
No
If so,please describe:
Do you have any dental problems now?
Yes
No
If so,please describe:
Have you ever had trouble with a previous dental treatment?
Yes
No
If so,please describe:
Level of anxiety about seeing the dentist (1 (least) and 5 (most)):
Date of last dental exam:
Date of last cleaning:
Date of last full mouth X-rays:
Procedure(s) done at last dental visit:
Previous dentist's name:
City:
State:
Phone:
Why are you changing dentists?
How often do you have dental examinations?
How often do you brush your teeth?
How often do you floss?
What type of bristles do you use?
Hard
Medium
Soft
What other dental aids do you use?
(Electric toothbrush,toothpick, etc.)
Do your gums ever bleed?
Yes
No
Have you noticed any mouth odors or bad tastes?
Yes
No
Are you sensitive to heat / cold?
Yes
No
Do you bite your lips or cheeks frequently?
Yes
No
Do you have frequent headaches?
Yes
No
Do you clench or grind your teeth?
Yes
No
Do you feel rested when you wake?
Yes
No

Have you ever had:
Periodontal disease/gum treatment?
Yes
No
Discomfort in your jaw joints (TMJ/TMD)?
Yes
No
Orthodontics treatment (Braces) ?
Yes
No
Your teeth ground or bite adjusted?
Yes
No
Oral surgery?
Yes
No
Serious injury to the mouth or head?
Yes
No
A bite plate or mouth guard?
Yes
No
If yes to any of the previous questions, please describe
Is there anything else about your past dental treatment(s) that you would like us to know?

Smile Analysis

1. Do you love the way your smile looks?
Yes
No
2. Do you feel comfortable showing your teeth when you laugh or smile?
Yes
No
3. If you could change anything about your smile,it would be(check all that apply):
Color of your teeth Too much or too little of teeth show when you smile Gaps between your teeth
Size or shape of your teeth Too much or too little of gum shows when you smile Alignment of your teeth
Other
4. Do you have(check all that apply):
Sensitive or receding gums Worn/broken/chipped teeth Old or discolored fillings
Missing teeth Old crowns that have dark edges at the top
Other
5. In your line of work or lifestyle, do you(check all that apply):
Visit businesses or clients Travel Speak publicly
Other
6. If you had a smile makeover do you think you'd feel?(check all that apply):
More confident More optimistic Healthier
Just OK No different
Other

We'd like to know more about you so we can server you better:
7. Do you have any special dates or upcoming events you'd like us to remember?(weddings,graduations, etc.)
8. What are your favorite hobbies or activities?
9. Is there anything else that you want our office to know about you that will help us to serve you better?

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 48 business hours notice are subject to a cancellation fee of $50 per appointment hour.

 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

Receiving Appointment Reminders Via Email and Text

Please check a source in which you would like to receive 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 Judy L.Disanti, DMD and Associates 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 Judy L.Disanti, DMD and Associates 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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