Online Registration

If this appointment is for you (fill in this section)
 
*
Indicates this field is a requirement on the page.
*
Name:
Address:
City:
State:
Zip:
Home Phone#:
Cell Phone#:
Cell Phone Carrier:
Work Phone#:
*
Email:
Date of birth
Marital Satus
SSN #:
How Did You Hear About Us?
Is there dental coverage?
Primary
Insurance Co:
Name of Insured:
Date of Birth:
Employer:
SSN #:
Member Identification #:
Secondary
Insurance Co:
Name of Insured:
Date of Birth:
Employer:
SSN #:
Member Identification #:
Personal Info
Patient Name  
1. Are you having pain or discomfort at this time?
Yes No
please describe:
 
2./ Have you been a patient in the hospital for the past 2 years?
Yes No
please describe:
 
3. Have you been under the care of a medical doctor during the past 2 years?
Yes No
    Physician Name:
    Phone:
 
4. Have you taken any medication or drugs during the past 2 years? Yes No
    Medication(s) name(s):
 
5. Are you now taken any medications, drug or pills? Yes No
    Medication(s) name(s):
 
6. Are you aware of being allergic to or have ever reacted adversely to any medication or substance? Yes No
    If so please list:
 
7. Please indicate which of the following you have had or have at present.
Heart Failure:Yes No Tuberculosis:Yes No
Heart Disease or attack:Yes No Asthma:Yes No
Angina Petcoris:Yes No Hey Fever:Yes No
Congenital Heart Disease:Yes No Allergies or Hives:Yes No
Heart Murmur:Yes No Sinus Trouble:Yes No
High Blood Pressure:Yes No Radiation Therapy:Yes No
Arteriosclerosis:Yes No Chemotherapy:Yes No
Mitral Valve Prolapse:Yes No Hepatitis A (infectious):Yes No
Artificial Heart Valve:Yes No Hepatitis B (serum):Yes No
Heart Pacemaker:Yes No Venereal Disease:Yes No
Heart Surgery:Yes No A.I.D.S.:Yes No
Rheumatic Fever:Yes No H.I.V. Positive:Yes No
Arthritis:Yes No Cold Sores/Fever Blisters:Yes No
Rheumatism:Yes No Blood Transfusion:Yes No
Cortisone Medicine:Yes No Hemophilia:Yes No
Drug Addiction:Yes No Anemia:Yes No
Stroke:Yes No Sickle Cell Disease:Yes No
Artificial Joins (hip, knee):Yes No Bruise Easily:Yes No
Kidney Trouble:Yes No Liver Disease:Yes No
Ulcers:Yes No Yellow Jaundice:Yes No
Diabetes:Yes No Epilepsy or Seizures:Yes No
Thyroid Problems:Yes No Fainting or Dizzy Spells:Yes No
Glaucoma:Yes No Nervousness:Yes No
Cosmetic Surgery:Yes No Psychiatric Treatment:Yes No
Emphysema:Yes No Developmentally Disabled:Yes No
Chronic Cough:Yes No Hepatitis C:Yes No
 
8. When you walk or climb stairs, do you ever have to stop because of pain in your chest? Yes No
    
 
9. Do your ankles swell during the day? Yes No
    
 
10. Have you ever been or are currently treated for any TMJ Disorder? Yes No
    
 
11. Do you have any pain or notice any popping or clicking noise when you eat or yawn? Yes No
    
12. Has your medical doctor ever said you have a cancer or tumor? Yes No
    
13. Do you have or have you had any disease, condition, or problem not listed? Yes No
    If yes, please list
14. For women only, Are you pregnant? Yes No
    What Month:
    Are you nursing:
 

Terms and Conditions

I hereby acknowledge that I have received a copy of the Notice of Privacy Practices describing the rights of the patient and our office’s obligations regarding the use and disclosure of dental information.

I authorize Bischoff Dentistry to take x-rays, study models, photographs or any other diagnostic aids deemed appropriate to make a thorough diagnosis of my dental needs.

I authorize Bischoff Dentistry to perform all recommended treatment mutually agreed upon by me and to use the appropriate medication and therapy indicated for such treatment. I understand that using anesthetic embodies a certain risk.

I understand that services will be billed to my insurance, and I authorize payment of the dental benefits to Bischoff Dentistry. I am responsible to pay my estimated portion when services are rendered. Due to ever-changing dental plans and coverage, I realize that the office is only able to give an approximation of the insurance balance. Therefore, if my insurance pays more than expected, my account will be credited and a refund issued. Conversely, if my insurance pays less than expected, I will be charged the difference. Final responsibility for payment rests with me.

Bischoff Dentistry will levy a service charge of 1.5% per month, compounded monthly or a minimum fee of $2.00 per month will be applied once my account is over 90 days past due. In the event that this account is assigned to a collection agency, I agree to pay all costs of collection, including court costs and attorney fees. I understand that I will not be allowed to return to the practice until the charges have been paid in full. In addition, in the event I claim bankruptcy prior to my bill being paid, I understand that I will not be allowed to return until any previous unpaid balances are paid in full.

Lastly, the above information is accurate and complete to the best of my knowledge. I will not hold Bischoff Dentistry responsible for any errors or omissions that I may have made in completing this patient registration. I agree that I am personally responsible for all dental bills that are incurred and to the extent not covered by insurance and will pay my portion of services rendered unless other arrangements have been made. As a courtesy to other patients, I will confirm my appointment and give the office 24 hour notice to reschedule my appointment. I understand otherwise, I will be levied $25 charge.


By checking this box I agree this is the same as my signature.

Date: 10/22/2017 3:47:19 PM
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