TLC Patient Registration
ID: ________ Cart ID: ___________
First Name: ___________________________ Last Name: ______________________ Middle Initial: _____
Patient is:
Policy Holder
Responsible Party
Preferred Name: __________________________
Who may we thank for referring you to our practice? ____________________________________________________________
Responsible Party (if someone other than the patient)
First Name: _____________________________ Last Name: _______________________________Middle Initial: _______
Address: _________________________________________ Address 2: ________________________________________
City, State, Zip: ________________________________________________ Pager: _______________________________
Home Phone: _________________ Work Phone: ___________________ Ext: _________ Cellular: __________________
Responsible Party is also a Policy Holder for Patient
Primary Insurance Policy Holder
Secondary Insurance Policy Holder
Patient Information
Address: _________________________________________ Address 2: ________________________________________
City, State, Zip: ________________________________________________ Pager: _______________________________
Home Phone: _________________ Work Phone: ___________________ Ext: _________ Cellular: __________________
Sex:
Male
Female
Marital Status:
Married
Single
Divorced
Separated
Widowed
Birth Date: __________________ Age: _______ Soc. Sec.: _____________________ Drivers Lic. __________________
E-Mail: _____________________________________________
I would like to receive correspondences via e-mail.
Are you available on short notice?
Yes
No
Do you have an AM or PM preference?
Yes
No
Primary Insurance Information
Name of Insured: ____________________________ Relationship to Insured:
Self
Spouse
Child
Other
Insured Soc. Sec: _____________________ Insured Birth Date: ________________
Employer: __________________________________
Ins. Company: ____________________________________
Address: ________________________________
Address: ______________________________________
Address 2: ________________________________
Address 2: _____________________________________
City, State, Zip: ______________________________
City, State, Zip: ___________________________________
Phone: ____________________________________
Phone: __________________________________________
Secondary Insurance Information
Name of Insured: ____________________________ Relationship to Insured:
Self
Spouse
Child
Other
Insured Soc. Sec: _____________________ Insured Birth Date: ________________
Employer: __________________________________
Ins. Company: ____________________________________
Address: ________________________________
Address: ______________________________________
Address 2: ________________________________
Address 2: _____________________________________
City, State, Zip: ______________________________
City, State, Zip: ___________________________________
Phone: ____________________________________
Phone: __________________________________________
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.
Are you under a physician’s care now?
Yes
No
Have you been hospitalized or had a major operation?
Yes
If yes, please explain ____________________________________
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 medications, pills, or drugs?
Yes
No
If yes, please explain ____________________________________
Do you take or have you taken Phen-Fen or Redux?
Yes
No
_____________________________________________________
Have you ever taken Fosamax, Boniva, Actonel or
_____________________________________________________
any other medications containing bisphosphonates?
Yes
No _____________________________________________________
Are you on a special diet?
Yes
No
Do you use tobacco?
Yes
No
Do you use controlled substances?
Yes
No
Women: are you
Pregnant / Trying to get pregnant?
Yes
No
Taking oral contraceptives?
Yes
No
Nursing?
Yes
No
Tell us a little about you.
What are your hobbies?___________________________________________________________________________________________
Anniversary date: ____/_____/________ Grandchildren? If so, what are their names? ________________________________________
How would you rate your smile?
Fair
Good
Excellent
Is there anything you would change about it if you could? ________________________________________________________________
Are you allergic to any of the following?
Aspirin
Other
Penicillin
Codeine
Acrylic
Metal
Latex
Local Anesthetics
Sulfa Drugs
If yes, please explain: ___________________________________________________________________
Do you have or have you had any of the following?
AIDS
Alzheimer’s Disease
Anaphylaxis
Anemia
Angina
Arthritis/Gout
Artificial Heart Valve
Artificial Joints
Asthma
Blood Disease
Blood Transfusion
Breathing Problem
Bruise Easily
Cancer
Chemotherapy
Chest Pains
Cold Sores/Fever Blisters
Congenital Heart Disorder
Convulsions
Cortisone Medicine
Diabetes
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 Pace Maker
Heart Trouble/Disease
Have you ever had any serious illness not listed above?
Hemophilia
Hepatitis A
Hepatitis B and C
Herpes
High Blood Pressure
Hives or Rash
Hypoglycemia
Irregular Heartbeat
Kidney Problems
Leukemia
Liver Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse
Osteoporosis
Pain in Jaw Joints
Parathyroid Disease
Psychiatric Care
Radiation Treatment
Yes
Recent Weight Loss
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
No If yes, please explain: ______________________________
______________________________________________________________________________________________________________
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.
Print Name: __________________________________________
SIGNATURE OF PATIENT, PARENT, or GUARDIAN ______________________________________ DATE: ______________________
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INITIAL DIAGNOSTIC PROCEDURES: In order to help formulate treatment recommendations, the following diagnostic procedures may be
performed: (1) A medical and dental history, (2) discussion of your dental problems, concerns and desires, (3) x-rays, (4) plaster casts of
the mouth and teeth, (5) examination of the mouth and associated structures, (6) photographs, and (7) conference with previous or
concurrent treating health professional. If additional diagnostic procedures or consultations are indicated, they will be discussed with you.
TREATMENT RECOMMENDATIONS: Are based on information gained from initial diagnostic procedures and previous experience and
may vary for similar situations. The ultimate goal of treatment is to assist you in attaining optimum dental health and appearance. We will
discuss with you the most appropriate and ideal treatment plan as well as reasonable alternative treatment plans. In those instances where
supporting structures are compromised, recommendations can be made only after consultation with specialists. We will also inform you of
the likely dental prognosis for each of these treatment plans and dental prognosis if no treatment is initiated at this time. You are welcome
at any time to seek a second opinion.
MEDICAL HISTORY: I understand the medical and dental history is necessary to provide me with dental care in a safe and efficient
manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask
the respective health care provider or agency. I will notify TLC Dentistry of any change in my health or medication prior to treatment.
TREATMENT: Upon such diagnosis, I authorize a TLC Dentistry dentist or a designated staff member to perform all recommended
treatment mutually agreed upon by me and to employ such assistance as required providing proper care.
INFORMED CONSENT AND AUTHORIZATION: I certify that I have read and understand this Informed Consent, which outlines the
general treatment considerations as well as the potential problems and complications of dental treatment. I understand that potential
complications and problems may include, but are not limited to, those described in this document and discussed with me. I understand that
during and following the treatment, and in the future, conditions may become apparent that warrant additional or alternative treatment
pertinent to the success of comprehensive treatment. Recognizing the potential problems and risks of dental treatment, authorization is
given for dental treatment to be rendered by the dentist and office staff. I also approve any modification in design, materials or care, if it is
felt this is for my best interest. This consent is in force indefinitely unless revoked by me in writing.
CONTACTS: I also give my permission to have TLC Dentistry personally contact me and remind me of needed appointments through the
U.S. Mail, (postcards or letters), e-mail, and/or voice messages at home or work.
PAYMENT: I agree to be responsible for payment of all services rendered on behalf of my dependents. I understand that payment is due at
the time of service unless other arrangements have been made. I authorize payment directly to TLC Dentistry of any insurance benefits
otherwise payable to me. I authorize the release of any information relating to dental claims.
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. We encourage you to
read it carefully and completely before signing this Consent.
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. You may obtain a copy of our Notice of Privacy Practices, including any revision of our Notice, at any time by
contacting:
George Lips, Business Manager, 750 East Romie Lane, Suite C, Salinas, CA 93901
Telephone: (831)757-1038
Fax: (831)757-5009
Email: Info@tlcdentistry.com
Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the
Contact Person listed above. 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.
Signature: I, ___________________________________________, 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 use and
disclose my protected health information to carry out treatment, payment activities and health care operations.
Signature: ________________________________________________________________________
Date:_____________________________________
If this Consent is signed by a personal representative on behalf of the patient, complete the following:
Personal Representative’s Name:________________________________________________________
Relationship to Patient:________________________________________________________________
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At TLC Dentistry, we believe that you deserve the best care. We will always present to you the best
dental solution possible to treat your personal needs, wants and desires. We provide outstanding
comprehensive dental care to all of our patients. Some have dental benefit plans and some do not. If
you have dental benefits, congratulations! You are very fortunate. Here are some important things you
should know….
Initial
________
Your dental benefits are based upon a contract made between your employer and an insurance
company. If you have any questions about your dental benefits please contact your employer or
insurance company directly. Dental benefits will never pay for completion of your dental care.
It is only meant to assist you.
________
We currently accept all PPO insurance plans. We work with literally hundreds of companies. Although
we can maintain computerized histories of payment by a given company, they do change: therefore it
is impossible to give you a guaranteed quote at the time of service. We estimate your portion based on
the most up-to-date information we have, but it is ONLY AN ESTIMATE. If you would like to know your
insurance benefits, we will be happy to file a “pre-treatment authorization” with your benefit company
prior to treatment. Keep in mind this is not a guarantee of coverage. This does delay treatment but will
give you the exact out of pocket figures you may require.
We will bill your insurance as a courtesy, if insurance does not pay within 90 days, TLC Dentistry
reserves the right to request payment in full for services from you and let you collect the insurance
funds that are due you. This is rare but it is important that you recognize that the insurance you have is
a legal contract between YOU and your insurance company. Our office is not, and cannot be part of
that legal contract. Ultimately, you are responsible for all charges incurred in our office.
TLC Dentistry does require payment in full for your portion at time of service. We accept MasterCard,
Visa, American Express, Discover, cash, and checks (for existing patients with established payment
history). We do not accept checks over $500.00 from any patient. If you are in need of an extended
finance option, we also work with CareCredit, who offers 3,6 or 12 month “same as cash” or longer
terms with an interest bearing revolving charge designed to meet your treatment plan need on
approved credit.
A specific amount of time is reserved especially for you and we strongly encourage all patients to keep
their appointments. If you must change your appointment, we require at least 48 hour notice to avoid
a $50.00/hour cancellation fee (emergencies are an exception).
In the event of an emergency after regular business hours a $55.00 emergency fee will be charged
for established patients in addition to the necessary treatment fees. Patients who are not established
in the practice will be charged $125.00 after hours emergency fee.
________
________
________
________
I agree with the above conditions.
Print Name: ______________________________________________________ Date: ____________________________
Patient/Parent Signature: ______________________________________________
VELscope Oral Cancer Screening
As a Healthcare provider, TLC Dentistry continually reviews new
medical technologies looking for those procedures that represent the
latest advances in medical care for our patients. We have recently
evaluated a new device and found that using it in conjunction with a
conventional visual oral examination enhances our ability to identify,
evaluate and monitor oral mucosal abnormalities. (In plain English…
we have the latest technology to help identify tissues that can be the
precursors to oral cancer and we can find it earlier than we can see it
with my naked eye.)
This painless, non-invasive visual test gives us a better chance to
find any oral abnormalities you may have, at the earliest possible
stage. This technology has successfully improved the identification of
pre-cancerous abnormalities in thousands of exams of squamous
epithelium of the cervix and has recently been cleared by the FDA for
an oral application. Early detection of such abnormalities can result in
the early treatment for pre-cancerous tissue. (In plain English… this
technique has been used for many years to help detect early tissue
changes in the lung cancer saving many lives by catching early)
This new device is called the VELscope and we are now offering it to
all of our patients at no cost.