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 )

I would like to receive email correspondences:
Yes
No

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

Please select below

Are You Married?
Yes No
Do You Have Primary Insurance?
Yes No
Do You Have Secondary Insurance?
Yes No
I have read the above choices

Spouse Information( * mandatory to fill )

Primary Insurance Information( * mandatory to fill )

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

Secondary Insurance Information( * mandatory to fill )

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

Please carefully read below:

I, THE UNDERSIGNED HEREBY AUTHORIZE THE DOCTOR TO TAKE X-RAYS, STUDY MODELS, PHOTOGRAPHS, OR ANY OTHER DIAGNOSTIC AIDS DEEMED APPROPRIATE BY THE DOCTOR TO MAKE A THOROUGH DIAGNOSIS OF THE PATIENTS DETERMINED NEEDS. I ALSO AUTHORIZE FLOSS DENTAL TO PERFORM ANY AND ALL FORMS OF TREATMENT, MEDICATION THAT MAY BE INDICATED. I ALSO UNDERSTAND THAT THE USE OF ANESTHETIC AGENTS EMBODIES A CERTAIN RISK AND UNDERSTAND THAT MY DENTAL INSURANCE IS A CONTRACT BETWEEN THE INSURANCE CARRIER AND ME, AND BETWEEN THE INSURANCE CARRIERS AND FLOSS DENTAL, AND THAT I AM FULLY RESPONSIBLE FOR ALL DENTAL FEES. THESE FEES ARE DUE AND PAYABLE AT THE TIME OF SERVICE. I ALSO ASSIGN ALL INSURANCE BENEFITS TO FLOSS DENTAL AND PAYMENTS RECEIVED BY THE DOCTOR FROM MY INSURANCE COVERAGE WILL BE CREDITED TO MY ACCOUNT AND WILL BE REFUNDED TO ME, UPON REQUEST, IF I HAVE PAID THE DENTAL FEES INCURRED. I FURTHER UNDERSTAND THAT AN ADDITIONAL CHARGE WILL BE ADDED TO ANY OVERDUE BALANCE. I HAVE READ AND UNDERSTAND THE NOTICE OF PRIVACY PRACTICE AS REQUESTED BY THE HEALTH INSURANCE PORTABILITY & ACCOUNTABILITY ACT OF 1996 (“HIPAA”).

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 been hospitalized or had a major operation?
Yes
No
Have you ever had a serious head or neck injury?
Yes
No
Are you taking any medication, pills or drugs?
Yes
No
Do you take, or have you taken, Phen-fen or Redux?
Yes
No
Are you on a special diet?
Yes
No
Do you use tobacco?
Yes
No
Do you use controlled substances?
Yes
No
Do you snore?
Yes
No
Have you been diagnosed with sleep apnea?
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?
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 Joint
Yes
No
Asthma
Yes
No
Blood Disease
Yes
No
Blood Transfusion
Yes
No
Breathing Problem
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
Convulsions
Yes
No
Cortisone medicine
Yes
No
Diabetes
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 Pace Maker
Yes
No
Heart Trouble / Desease
Yes
No
Hemophilia
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 Problems
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 above?
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.

SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )
I have answered all the above questions

times per Floss times per
How do you feel about dental treatment?
Relaxed
A little uneasy
Tense
Anxious
Very Anxious
Do you have or have you ever had any of the following? Please mark boxes and comment.
If you could change your smile, what would you change?
I have answered all the above questions

CONSENT FOR TREATMENT

I, the undersigned, hereby authorize the doctor to take radiographs, study models, photographs or any other diagnostic aids he/she deems appropriate to make a thorough diagnosis of my dental needs. I also authorize the doctor to perform any and all forms of treatment, medication and therapy that may be indicated. I authorize and consent that the doctor employ any such assistance as he/she deems appropriate.

I further authorize the release of any information, including the diagnosis, radiographs and records of any treatments or examinations rendered to my insurance company, consulting professionals or others that may request my records. I understand that I am personally responsible for payment of all fees for dental services provided in this office for me or my dependents, regardless of insurance coverage. Breach of this responsibility carries the penalty of compensating the practice for any related attorney’s and collection fees. I understand that payment is due when services are rendered. Any other arrangements for payment must be made before treatment begins.

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

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

The Health Insurance Portability & Accountability Act of 1996 (“HIPAA”) is a federal program that requires all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information.
As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information. If you sign a Consent Form, we may use and disclose your medical records only for each of the following purposes: treatment, payment and healthcare operations.

  • Treatment means providing, coordinating, or managing healthcare and related services by one or more healthcare providers. An example of this would include teeth cleaning services.
  • Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment.
  • Healthcare operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost management analysis, and customer service. An example would be an internal quality assessment review.

We may also create and distribute de-identified health information by removing all references to individually identifiable information. We may, without prior consent, use or disclose protected health information to carry out treatment, payment, or healthcare operations in the following circumstances:

  • In emergency treatment situations, if we attempt to obtain such consent as soon as reasonably practicable after the delivery of such treatment;
  • If we are required by law to treat you, and we attempt to obtain such consent but are unable to contain such consent; or
  • If we attempt to obtain your consent but are unable to do so due to substantial barriers to communicating with you, and we determine that, in our professional judgment, your consent to receive treatment is clearly inferred from the circumstances. We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization. You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer:

  • The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
  • The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.
  • The right to inspect and copy your protected health information.
  • The right to amend your protected health information.
  • The right to receive an accounting of disclosures of protected health information.
  • The right to obtain a paper copy of this notice from us upon request.

We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information. This notice is effective as of October 17, 2002 and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office. You have recourse if you feel that your privacy protections have been violated. You have the right to file a formal, written complaint with us at the address below, or with the Department of Health & Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint.

I do NOT authorize any information to be discussed with any family members or friends.
I authorize information about treatment or appointments to be discussed with the following person(s):
I have read and understand the above information
SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )
Thank you for visiting FLOSS Dental. We want your visit to be pleasant and comfortable. Please help us by completing this form
Patient Information

Personal Details

Title:           First Name:           Last Name:          
Date Of Birth:           Gender:          
Address:           City:           State:           Zip:          
Email Address:          
I would like to receive email correspondences Yes No

How do we contact you?

Home Phone:           Cell Phone:           Work Phone:          
Driver's License:           How did you hear about us         
Social Security Number:           Emergency Contact:           Phone:          

Spouse Information

Spouse Name: Date Of Birth Phone Number: Employer:
Are You Married? Yes No

Primary Insurance Information

Name of Insured:           Relationship to Patient:           Insured's Employer:          
Employer Phone:           Insurance Company:           Insurance Phone:          
Do You have Primary Insurance? Yes No

Secondary Insurance Information

Name of Insured:           Relationship to Patient:           Insured's Employer:           Employer Phone:           Insurance Company:           Insurance Phone:          
Do You have Secondary Insurance? Yes No

Please carefully read below:

I, THE UNDERSIGNED HEREBY AUTHORIZE THE DOCTOR TO TAKE X-RAYS, STUDY MODELS, PHOTOGRAPHS, OR ANY OTHER DIAGNOSTIC AIDS DEEMED APPROPRIATE BY THE DOCTOR TO MAKE A THOROUGH DIAGNOSIS OF THE PATIENTS DETERMINED NEEDS. I ALSO AUTHORIZE FLOSS DENTAL TO PERFORM ANY AND ALL FORMS OF TREATMENT, MEDICATION THAT MAY BE INDICATED. I ALSO UNDERSTAND THAT THE USE OF ANESTHETIC AGENTS EMBODIES A CERTAIN RISK AND UNDERSTAND THAT MY DENTAL INSURANCE IS A CONTRACT BETWEEN THE INSURANCE CARRIER AND ME, AND BETWEEN THE INSURANCE CARRIERS AND FLOSS DENTAL, AND THAT I AM FULLY RESPONSIBLE FOR ALL DENTAL FEES. THESE FEES ARE DUE AND PAYABLE AT THE TIME OF SERVICE. I ALSO ASSIGN ALL INSURANCE BENEFITS TO FLOSS DENTAL AND PAYMENTS RECEIVED BY THE DOCTOR FROM MY INSURANCE COVERAGE WILL BE CREDITED TO MY ACCOUNT AND WILL BE REFUNDED TO ME, UPON REQUEST, IF I HAVE PAID THE DENTAL FEES INCURRED. I FURTHER UNDERSTAND THAT AN ADDITIONAL CHARGE WILL BE ADDED TO ANY OVERDUE BALANCE. I HAVE READ AND UNDERSTAND THE NOTICE OF PRIVACY PRACTICE AS REQUESTED BY THE HEALTH INSURANCE PORTABILITY & ACCOUNTABILITY ACT OF 1996 (“HIPAA”).

 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS
Medical History
Are you under a physicians 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:
Do you take, or have you taken, Phen-fen or Redux?
Yes
No
Are you on a special diet?
Yes
No
Do you use tobacco?
Yes
No
Do you use controlled substances?
Yes
No
Do you snore?
Yes
No
Have you been diagnosed with sleep apnea?
Yes
No
Are you a woman?
Yes
No
Pregnant/trying to get pregnant Nursing Taking oral contraceptives None
Are you allergic to any of the following?
Aspirin Penicillin Codeine Acrylic
Metal Latex Sulfa drugs Local anesthetics
Others
If Others, Please Specify:
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 Joint Asthma
Blood Disease Blood Transfusion Breathing Problem
Bruise Easily Cancer Chemotherapy
Chest Pain 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 / Desease Hemophilia
Hepatitis A Hepatitis B or C Herpes
High Blood Pressure High Cholesterol Hives or Rash
Hypoglycemia Irregular Heartbeat Kidney Problems
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 above?
Yes
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.

 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS
Dental History
Reason for seeking dental care at this time:           Date of last dental visit:          
Last Dental Visits Reason:           Date of last X-rays:           Former dentist:          
City:           State:          
times per Floss times per
How do you feel about dental treatment?
Relaxed
A little uneasy
Tense
Anxious
Very Anxious
Do you have or have you ever had any of the following? Please mark boxes and comment
Aching or sensitive teeth Broken filling Areas of food traps Unfavorable dental experience
Sensitive or bleeding gums Loose teeth Difficulty opening wide Growths or lesions in your mouth
Broken or missing teeth Bad breath Clicking or popping in jaw Cold sores
Grinding or clenching Swollen glands Jaw pain or tiredness Dry mouth
Swelling or lumps in mouth Gum infection Orthodontic treatment Other
If Other, Please Specify:
If you could change your smile, what would you change?
Remove unsightly fillings Straighten teeth Change shape of teeth Close gaps between teeth
Replace missing teeth Whitening Make teeth same color Other
If Other, Please Specify:

CONSENT FOR TREATMENT

I, the undersigned, hereby authorize the doctor to take radiographs, study models, photographs or any other diagnostic aids he/she deems appropriate to make a thorough diagnosis of my dental needs. I also authorize the doctor to perform any and all forms of treatment, medication and therapy that may be indicated. I authorize and consent that the doctor employ any such assistance as he/she deems appropriate.

I further authorize the release of any information, including the diagnosis, radiographs and records of any treatments or examinations rendered to my insurance company, consulting professionals or others that may request my records. I understand that I am personally responsible for payment of all fees for dental services provided in this office for me or my dependents, regardless of insurance coverage. Breach of this responsibility carries the penalty of compensating the practice for any related attorney’s and collection fees. I understand that payment is due when services are rendered. Any other arrangements for payment must be made before treatment begins.

Relationship:          
The information on this page is correct to the best of my knowledge.
 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

The Health Insurance Portability & Accountability Act of 1996 (“HIPAA”) is a federal program that requires all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information.
As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information. If you sign a Consent Form, we may use and disclose your medical records only for each of the following purposes: treatment, payment and healthcare operations.

  • Treatment means providing, coordinating, or managing healthcare and related services by one or more healthcare providers. An example of this would include teeth cleaning services.
  • Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment.
  • Healthcare operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost management analysis, and customer service. An example would be an internal quality assessment review.

We may also create and distribute de-identified health information by removing all references to individually identifiable information. We may, without prior consent, use or disclose protected health information to carry out treatment, payment, or healthcare operations in the following circumstances:

  • In emergency treatment situations, if we attempt to obtain such consent as soon as reasonably practicable after the delivery of such treatment;
  • If we are required by law to treat you, and we attempt to obtain such consent but are unable to contain such consent; or
  • If we attempt to obtain your consent but are unable to do so due to substantial barriers to communicating with you, and we determine that, in our professional judgment, your consent to receive treatment is clearly inferred from the circumstances. We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization. You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer:

  • The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
  • The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.
  • The right to inspect and copy your protected health information.
  • The right to amend your protected health information.
  • The right to receive an accounting of disclosures of protected health information.
  • The right to obtain a paper copy of this notice from us upon request.

We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information. This notice is effective as of October 17, 2002 and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office. You have recourse if you feel that your privacy protections have been violated. You have the right to file a formal, written complaint with us at the address below, or with the Department of Health & Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint.

 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS
I do NOT authorize any information to be discussed with any family members or friends.
I authorize information about treatment or appointments to be discussed with the following person(s)
 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

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