Larsen Family Dentistry Emergency Patient Registration
First Name:
Last Name:
Preferred Name:
Sex:
Mailing Address:
Middle Initial:
Male
Female
City, State, Zip:
Home Phone:
Work Phone:
Cell Phone:
Birth Date:
(ext)
Age:
Please check which phone numbers are the most convenient for use.
Responsible Party (if different from the patient):
Mailing Address:
Home Phone:
City, State, Zip:
Work Phone:
Birth Date:
(ext)
Cell Phone:
Email Address:
**As a courtesy, we will submit to your dental insurance if you are local only. Those visiting from out-of-state we kindly ask
you pay your bill at the date services are rendered and we will give you the information needed to submit to your own
insurance.
PRIMARY DENTAL INSURANCE INFORMATION
Name of Insured:
Insured Birth Date:
Relationship to Insured:
Insured Social Security:
Self
-
Insured ID #:
Group #:
Insured Employer:
Insurance Company:
Insurance Phone #:
Address:
City, State, Zip:
Dental Information:
Please describe the reason for your emergency:
If in pain, how long have you been so?
Spouse
-
Child
Other
Larsen Family Dentistry Emergency Patient Registration
Are you under a physician’s care? Yes
no
If yes, please specify:_______________________________________________________________
Have you ever been hospitalized or had a major operation? Yes
no
If yes, please specify _________________________________________________________________________________________________________________________
Have you ever had a serious head or neck injury? Yes
no
If yes, please specify ____________________________________________
Please list any medications, pills, or drugs:
_________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
Have you ever taken Fosamax, Boniva, Actonel, Evista, Prempro, Premphase or any other medications containing
bisphophonates?
Yes
no
If yes, please specify _________________________________________________________________________
Are you on a special diet? ___________________________________________________________________________________________________________________
Do you use any tobacco products?
Yes
no
If yes, please specify _____________________________________________________
Do you use any illegal drugs or drugs controlled by the government?
Yes
no
Women, are you (please circle what may apply):
Pregnant
Trying to get pregnant
infrequent care during pregnancies
Nursing taking oral contraceptives
menopause
Are you allergic to any of the following:
Aspirin Penicillin
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Codeine Acrylic Metal
Please check all that apply:
Aids/HIV
Angina
Artificial Heart Valve
Artificial Joint
Asthma
Blood Disease
Blood Transfusion
Breathing Problems
Cancer
Chemotherapy
Cold Sores / Fever Blisters
Congenital Heart Disorder
Diabetes
Drug Addiction
Tuberculosis
Tumors or Growths
Ulcers
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Latex
Epilepsy or Seizures
Fainting Spells
Frequent Cough
Frequent Headaches
Genital Herpes
Heart Attack/Failure
Heart Murmur
Heart Pacemaker
Heart Trouble/Disease
Hepatitis A
Hepatitis B or C
High Blood Pressure
High Cholesterol
Irregular Heartbeat
Please list anything not listed above, or if you have any comments:
Signature:
Sulfa Drugs
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Local Anesthetics
Kidney Problems
Liver Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse
Osteoporosis
Pain in Jaw Joints
Psychiatric Care
Radiation Treatments
Shingles
Sinus Trouble
Stomach/Intestinal Disease
Stroke
Thyroid Disease
Larsen Family Dentistry Emergency Patient Registration
CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION AND OFFICE POLICIES
PLEASE READ THE FOLLOWING CAREFULLY:
PURPOSE OF CONSENT: By signing this form, you will consent to our use and disclosure of your protected health information to
carry out treatment, payment activities and healthcare operations.
NOTICE OF PRIVACY PRACTICES: You have the right to read our Notice of Privacy Practices before you decide whether to
sign this Consent. Our notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and
disclosures we may make of your protected health information, and of other important matters about your protected health
information. A copy of our Notice can be found at the front desk when asked. We reserve the right to change our privacy practices as
described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices,
which will contain the changes. Those changes may apply to any of your protected health information that we maintain.
If you decide to pay for your treatment in full on the date of service and do not want your insurance to be billed, you have the right to
request not to disclose treatment information for this service to a health plan.
If applicable, a patient has the right to an Electronic copy of their records if they prefer.
YOU MAY OBTAIN A COPY OF OUR Notice of Privacy Practices, INCLUDING ANY REVISIONS OF OUR NOTICE, AT
ANY TIME, BY CONTACTING US.
RIGHT TO REVOKE: You will have the right to revoke this consent at any time by giving us written notice of your revocation.
Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received
your revocation, and that WE MAY DECLINE TO TREAT YOU OR TO CONTINUE TREATING YOU if you revoke this
consent.
Authorization and Release of Records
I authorize Larsen Family Dentistry to release any information, including the diagnosis and the records of any treatment or
examination rendered to me or my child during the period of such dental care, to third party payers and/or health practitioners. I agree
to be responsible for payment of all services rendered on my behalf or my dependents. I agree to allow Larsen Family Dentistry to
leave messages concerning my appointments and/or results on my answering machine or with family members.
Payment Policy
- Payment is expected at the time the service is rendered. We will accept
Cash
Personal checks The following Credit Cards: Visa, MasterCard, DiscoverCard
- Non-insured patients are expected to make payment in full on the day the service is rendered, unless definite arrangements
have been made with our office manager PRIOR TO TREATMENT.
- Patients with dental insurance are expected to pay the portion of the total fee not covered by their insurance on the day of
service. The “Patient Portion” is ONLY an estimated dollar amount.
AS A COURTESY, our office will file your claim with your insurance company, and initiate correspondence with the purpose of
getting you the maximum coverage your insurance will allow; however, if we do not receive payment from your insurance company
within 60 days, the payment becomes your responsibility.
- It is the PATIENT’S responsibility to know and understand his/her insurance coverage. Larsen Family Dentistry will be
happy to give you the number of your insurance company to contact them with further questions.
- The patient is ALWAYS responsible for seeing that the ENTIRE FEE is paid in full.
- If payment is not taken care of by the insurance or the patient within 90 days, there will be a fee added to the account, and the
account will be sent to Collections.
Reminder Policy
- AS A COURTESY, Larsen Family Dentistry gives reminders of the patients’ appointments via mail and phone. However, it
is the patient’s responsibility to remember their appointments and be on time. It is not the responsibility of the office if the
patient does not receive the reminders and forgets his/her appointment, which will result in a failed appointment fee.
Cancellation Policy
To achieve the highest level of patient care and time management, our office requires appointment changes to occur within the office
hours (7:00am to 3:00pm) the day before (24 hours) the appointment date. Failure to do so will result in a $50.00 failed appointment
fee.
AS A PATIENT/RESPONSIBLE PARTY AT LARSEN FAMILY DENTISTRY I UNDERSTAND AND AGREE TO THE ABOVE
POLICIES
PRINT _____________________________________________________, have had full opportunity to read and consider the contents
of this Consent form and your Notice of Privacy Practices. I understand that by signing this Consent form, I am giving my consent to
your use and disclosure of my protected health information to carry our treatment, payment activities and health care operations.
SIGNATURE
____________________________________________________________DATE_______________________________
IF SIGNED BY REPRESENTATIVE OR ON BEHALF OF THE PATIENT, COMPLETE THE FOLLOWING:
NAME _________________________________________RELATIONSHIP TO PATIENT _____________________
YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT.