Premier Dental
Daniel J. Beninato, D.D.S. & Associates
Restorative and Cosmetic Dentistry
PATIENT REGISTRATION
First Name:
Last Name:
Middle Initial:
Patient Is:  Responsible Party  Policy Holder
Preferred Name:
Section 1 - Patient Information
Address:
formation jyj
City:
Home Phone:
Work Phone:
Birth Date:
Soc. Sec. #:
Sex:  Male
 Female
State:
Ext:
Zip Code:
Cell:
Drivers License #:
Marital Status:  Married  Single  Divorced  Separated  Widowed
 I would like to receive correspondences via e-mail
Email:
Responsible Party (If someone other than patient. ex. policy holder, spouse, parent, legal guardian)
Name:
Address:
City:
State:
Home Phone:
Work Phone:
Birth Date:
Soc. Sec. #:
Section 2
Employment Status:  Full Time  Part Time  Retired
Zip Code:
Ext:
Cell:
Drivers License #:
Student Status:  Full Time  Part Time  N/A
Preferred Pharmacy & Location:
Section 3
Referred By:  T.V  Radio  Ins. Book  Internet  Flyer  Location  Patient:
Your Employer:
Your Occupation:
Spouse's Employer:
Spouse's Work #:
 Other
Emergency Contact Name & Phone #:
Primary Care Physician Name & Phone #:
Primary Insurance Information
Name of Insured:
Relationship to Insured:  Self  Spouse  Child  Other
Insured Soc. Sec. #:
Insured Birth Date:
Employer:
Insured Company:
Address:
Address:
City, State, Zip:
City, State, Zip:
Secondary Insurance Information
Name of Insured:
Relationship to Insured:  Self  Spouse  Child  Other
Insured Soc. Sec. #:
Insured Birth Date:
Employer:
Insured Company:
Address:
City, State, Zip:
Premier DentalAddress:
Daniel J. Beninato, D.D.S. & Associates
City, State, Zip:
Medical History
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Medical History
Patient Name:______________________________________________________
Are you under a physician's care now? O Yes O No
Date:
If yes:
Have you ever been hospitalized or had a major operation? O Yes O No
If yes:
Have you ever had a serious head or neck injury? O Yes O No
If yes:
Are you taking any medications, pills, or drugs? O Yes O No
If yes:
Have you ever taken Fosamax, Boniva, Actonel or O Yes O No
any other medications containing bisphosphonates?
If yes:
Are you on a special diet? O Yes O No
Do you use tobacco? O Yes O No
Are you allergic to any of the following?
O Aspirin
O Penicillin
O Codeine
O Sulfa Drugs
O Local Anesthetics
Women: Are you...
O Pregnant?
O Acrylic
O Other? If yes:
O Nursing?
O Metal
O Latex
O Taking Oral Contraceptives?
Do you have, or have you had, any of the following?
Aids/HIV Positive
Alzheimer's Disease
Anemia
High Blood Pressure
Artificial Heart Valve
Hypoglycemia
Sinus Trouble
Frequent Headaches
Low Blood Pressure
Chemotherapy
Heart Attack/Disease
Tumors
Psychiatric Care
Neurological Disorder
More than 1 alcoholic
Beverage per day
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
Cortisone Medicine
Diabetes
Herpes
Arthritis/Rheumatism
Excessive Bleeding
Sickle Cell Disease
Blood Disease
Liver Disease
Swelling of Limbs
Mitral Valve Prolapse
Osteoporosis
Congenital Heart Disorder
Yellow Jaundice
Nervous/Anxious
TMJ Noise/Pain
Have you ever had any serious illness not listed?
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
O Yes O No
Hemophilia
Recent Weight Loss
Rheumatic Fever
Epilepsy or Seizures
Artificial Joint
Asthma
Kidney Problems
Stroke
Glaucoma
Tonsil Problem/Surgery
Tuberculosis
Heart Pacemaker
Seasonal Allergies
Snore
Cancer
Type:______________
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
Radiation Treatments
Hepatitis A, B, or C
Emphysema
High Cholesterol
Excessive Thirst
Fainting Spells/Dizziness
Blood Transfusion
Bruise Easily
Thyroid Problems
Chest Pains
Heart Murmur
Ulcers
Shortness of Breath
Trouble breathing when asleep
Other:________________
______________________
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
If yes:
Please write in any other pertinent information that has not been covered.
Authorization: I hereby authorize the Doctor and/or team member of this dental office to administer such medications and to perform such
diagnostic and therapeutic procedures as may be necessary for proper dental care as agreed upon through consultation with me. The
information which appears, on these medical and dental histories is correct to the best of my knowledge. I also authorize the doctor and/ or
team member to contact my healthcare giver(s) concerning my treatment if necessary.
Patient Signature
Date
The Financial Policies
Of
Premier Dental
Daniel J. Beninato, D.D.S. & Associates
Restorative and Cosmetic Dentistry
In an effort to keep dental costs down, while maintaining a high level of professional care, we have established a financial
policy for your benefit. For your ease and convenience, we offer the following types of financial arrangements:
1.) All payments are due the day of the appointment. Any appointments 60 minutes or more we will collect the co-pay
one week prior to reserve your scheduled time, unless previous arrangements have been made.
2.) In an effort to help make high quality dental care affordable, we are able to help arrange financing for your dental
treatment. Please ask about our no interest credit financing available upon credit approval. As another service to our
patients, we are able to securely store a credit card number in our system in order to make payments, which you may
authorize prior to your appointment.
I understand my payment options, and that I am responsible for all my dental fees. I also understand that missed or broken
appointments without 2 business days notice increases the cost of dental treatment, and that there may be a charge for
missed or broken appointments.
Patient Signature
Date
Do you accept my insurance? How much will they pay?
Our entire team is pleased that you have insurance benefits to help you and your family with the cost of your dental care. We
would like to help you obtain the maximum use of these benefits. With this in mind, please read the information on our
insurance claims process so we can work together to ensure this benefit.
We currently accept most private care insurance plans, which means that we work with hundreds of companies. The extent of
your coverage varies greatly from company to company, sometimes even within a company. Although we maintain
computerized histories of payment by a given company, they change; therefore it is impossible to give you a guaranteed
quote at the time of service. We do, however provide a complimentary benefits check at your first visit. We estimate your
portion based on the most up to date information we have, but it is only an estimate. It is the responsibility of the patient to
be aware of individual policy limitations and requirements. As a service to our patients, we are able to help you by
electronically filing your claim for your insurance reimbursement.
I hereby authorize Premier Dental to release any information for insurance claim filing purposes.
Patient Signature
Date
Over--->
NOTICE OF PRIVACY PRACTICES
Daniel J. Beninato, D.D.S. & Associates
17110 Lakeside Hills Plaza Omaha, NE 68130
402.330.6757
Office contacts: cathe@premiersmile.com or amy@premiersmile.com
I give this practice my consent to use or disclose my protected health information to carry out my treatment, to obtain
payment from insurance companies, and for health care operations like quality reviews.
I have been informed that I may review the practice’s Notice of Privacy Practices (for a more complete description of uses and
disclosures) before signing this consent.
I understand that this practice has the right to change their privacy practices and that I may obtain any revised notices at the
practice.
I understand that I have the right to request a restriction of how my processed health information is used. However, I also
understand that the practice is not required to agree to the request. If the practice agrees to my requested restriction, they
must follow the restrictions.
I also understand that I may revoke this consent at any time, by making a request in writing, except for information already
used or disclosed.
Patient Signature
Date
Photography Release
I, _________________________, hereby consent and authorize Dr. Beninato and his team at Premier Dental to take
photographs, slides, and/or videos of my face, jaws and teeth.
I understand that the photographs, slides, and/or videos will be used as a record of my care, and may be used with or without
my given name or with a fictitious name for educational purposes in lectures, demonstrations, advertising, professional
publications (dental magazines and journals) and any other lawful purpose.
I release and forever discharge Dr. Beninato or any member of Premier Dental from any claim, demands, or liability on
account of such use or for the quality of the reproduction of the image.
Patient Signature
Date
Witness
Date
Minors Only: If the signature above is by a person under the age of 18, parent or guardian should sign here:
I,
, parent or guardian hereby consents to the release as stated above.