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 )

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

Who do we contact in case of an emergency?( * mandatory to fill )

Please select below

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

Primary Insurance and/or Person Responsible for Payment( * mandatory to fill )

POLICY HOLDER : SELF OTHER
SIGNATURE (Parent’s if minor)
 

To the best of my knowledge, the information above is correct. I realize that this office will provide insurance billing and assist with insurance benefits to the best of it’s knowledge. However, all charges for services are ultimately my responsibility.

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

Secondary Insurance Information( * mandatory to fill )

POLICY HOLDER : SELF OTHER
SIGNATURE (Parent’s if minor)
 

To the best of my knowledge, the information above is correct. I realize that this office will provide insurance billing and assist with insurance benefits to the best of it’s knowledge. However, all charges for services are ultimately my responsibility.

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

Medical History

Excellent Good Fair

Answers to the following are for our records and are confidential (* )

Are you under current medical treatment?
Yes
No
Are you currently taking any medications or herbal supplements?
Yes
No
Do you have allergies or adverse reaction to drugs?
Yes
No
Have you ever taken I.V. or oral Bisphosphonates for bone density such as Fosamax, Actonel, Boniva, Aredia, Zometa or Bonefos
Yes
No
Are you on a special diet?
Yes
No
Have you lost or gained more than 10 pounds in the past year?
Yes
No
Do you use any form of tobacco?
Yes
No
Are you interested in quitting?
Yes
No
Do you consume alcohol?
Yes
No
I have answered all the above questions

Medical History

Women, are you:
Yes
No
I have answered all the above questions

Medical History

Do you have or have you ever had any of the following?

Rheumatic Fever
Yes
No
Diabetes/FAMILY HISTORY
Yes
No
Respiratory Disease
Yes
No
High Blood Pressure/FAMILY HISTORY
Yes
No
Heart Murmur
Yes
No
Stroke/FAMILY HISTORY
Yes
No
Heart Disease/FAMILY HISTORY
Yes
No
Epilepsy
Yes
No
Other Heart Ailment
Yes
No
Head Injuries
Yes
No
Chemo/Radiation Therapy
Yes
No
Caffeine Dependency
Yes
No
Mitral Valve Prolapse
Yes
No
Psychological/Psychiatric Treatment
Yes
No
Cancer
Yes
No
Bleeding Problems
Yes
No
Artificial Joints
Yes
No
Blood Transfusion
Yes
No
Liver Disease
Yes
No
Latex Sensitivity
Yes
No
HIV or AIDS
Yes
No
Organ Transplant
Yes
No
Kidney Disease/FAMILY HISTORY
Yes
No
Venereal Disease INCLUDES HPV+
Yes
No
Arthritis/FAMILY HISTORY
Yes
No
Hepatitis
Yes
No
Major Operations
Yes
No
Pacemaker
Yes
No
Have you ever been told you need Antibiotics prior to treatment
Yes
No
Do you have a disease or condition not listed
Yes
No
Dementia/Alzheimers/FAMILY HISTORY
Yes
No
Gum Disease/FAMILY HISTORY
Yes
No
I have answered all the above questions

What is your immediate dental concern?
Do you have dental pain now?
Yes
No
When was your last dental visit?
What was done at that appointment?
When was your last cleaning and exam?
Were x-rays taken?
Who was your previous dentist?
Previous Dentist's City
Previous Dentist's Phone
What influenced you to change dentists?
Are any of your teeth sensitive to hot or cold?
Yes
No
Biting or chewing pain?
Yes
No

Please check if you have or have ever had:

Unfavorable dental experiences
Yes
No
Difficulty opening your mouth widely
Yes
No
Dental fears
Yes
No
Stiff or sore head, neck & shoulder muscles
Yes
No
Preference for no dental anesthetic
Yes
No
Do you wake up with tooth or jaw pain
Yes
No
Tension headaches
Yes
No
Clench or grind your teeth
Yes
No
Jaw clicking or popping
Yes
No
Bleeding gums
Yes
No
Any oral appliances
Yes
No
Any removable teeth
Yes
No
Family history of diabetes
Yes
No
Part of your mouth sensitive to temperature 
Yes
No
Lumps or bumps on head or neck
Yes
No
Dry mouth
Yes
No
Do you have a sugar or soda pop habit
Yes
No
Unpleasant taste or odor in your mouth
Yes
No
Noticed loose teeth or a change in your bite
Yes
No
Viral infection or cold sores
Yes
No
Jaw problems (TMJ)
Yes
No
Orthodontic treatment (braces)
Yes
No
How often do you: Brush
Yes
No
How often do you: Floss
Yes
No
Parents who have lost teeth or had gum disease
Yes
No
Breath through your mouth while awake or asleep
Yes
No
Problems with effectiveness of or bad reactions to dental anesthetic
Yes
No
Habitual chewing of hard substances ie, ice, popcorn kernels
Yes
No

Not Important   1   2   3   4   5   6   7   8   9   10 Very Important

Unpleasant   1   2   3   4   5   6   7   8   9   10 Beautiful

To the best of my knowledge, the information above is correct. I realize that this office will provide insurance billing and assist with insurance benefits to the best of its knowledge. However, all charges for services and collection costs for untimely payments are ultimately my responsibility.

Treatment Authorization

The information on this page is correct to the best of my knowledge. I authorize and give consent to perform dental services agreed between doctor and patient and/or parent or guardian to be necessary or advisable including the use of local anesthesia and other medication as indicated. I certify to the above statements regarding my medical condition.

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

General Consent

1. During the course of treatment, I may undergo procedures in all phases of dentistry including periodontics (gum treatment and surgery), oral surgery, endodontics (root canals), fixed and removable prosthodontics (crowns, bridges, and dentures), implant dentistry, restorative dentistry, temporomandibular disorder treatment, sleep apnea treatment, oral pathology, pediatric dentistry, and radiography. Some of the procedures may be performed by a dental profession other than the dentist including a dental assistant or dental hygienist that have been trained to perform certain tasks and is allowable by Florida law.

2. I will provide a thorough and complete medical history, supply a full list of my medications with dosages, and consent to my dentist communicating with my other medical practitioners to inquire about any aspect of my health history.

3. No guarantees can be made about treatment outcomes, restoration longevity, or prognoses. I understand that any branch of medicine, including dentistry, can involve unanticipated results.

4. Payment is due the day of service and I am responsible for the full amount owed regardless of any insurance policy I may or may not have. The practice will help in filling any forms needed for insurance reimbursement and those payments will be given to the patient. There is no guarantee that an insurance company will cover work that may be performed.

5. My treatment plan may change at any time and I will do my best to approach my dental care with optimism and open communication with my dentist, hygienist, and dental office staff.

6. I am welcome to ask questions about any aspects of my dental care and will request information if I am confused or need more information. I am responsible for clarifying any aspects of my treatment that I am unsure about.


Most dental procedures require the use of dental anesthetic or numbing to complete the procedure. I understand that there are risks involved in using anesthetic which include permanent or temporary loss of feeling and or muscle control from nerve damage, pain from injection site including muscle tightness or even muscle damage that may or may not go back to normal, allergic reaction, and any other side effects as
SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

Missed Appointment / Cancellation Policy

Due to the high number of patients requiring dental care, waiting times for appointments can be long. Because of this, we enforce a missed appointment policy to ensure that other patients receive care in a timely manner. Missed appointments and appointments cancelled without 24-hour notice are subject to a cancellation fee of 50$.

Recieve Appointment Reminders Via Email And Text

Please check a source in which you would like to recieve appointment reminders.*

Email  
Text Message  
Both Email and Text Message

We use this information to provide you with excellent treatment. We may disclose Patient Health Information (PHI) to third parties that perform services for Eby Dental Care in the administration of your benefits in accordance with HIPAA. These parties are required by law to sign a contract agreeing to protect the confidentiality of your PHI. Your PHI may be disclosed to an affiliate that performs services for Eby Dental Care in the administration of your benefits. Our affiliates do not sell, share or rent our users’ personally identifiable information unless required by law, do not send and e-mail or other communications without user permission, and do not send spam.

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

HIPAA NOTICE

HIPAA

Health Insurance Portability and Accountability Act

Legal Duty

Eby Dental Care is required by law to protect the privacy of your personal health information, provide this notice about our information practices and follow the information practices that are described herein.

Uses and Disclosures of Health Information

Eby Dental Care uses your personal health information primarily for treatment, obtaining payment for treatment, conducting internal administration and evaluating the quality of care that we provide. Some examples of uses of your personal health information may include, but are not limited to, the following: (1) Contacting you by telephone/mail and leaving a message if necessary to provide or obtain information regarding appointments, your treatment, your patient account, treatment alternatives or other health related benefits and services that we offer, and/or company news; (2) Obtaining information from your referral source in order to schedule an appointment and to verify/authorize insurance benefits, (3) Announcing your arrival to the therapist in an area where others may hear the information, (4) Calling out your name in the waiting area, (5) Placing your encounter form and/or medical record in a slot beside your treatment room door, (6) Treating you in an open area where conversations between you and your therapist may be overheard buy other patients and staff, (7) Sharing information as needed with other health care providers involved in your care, (8) Performing quality assurance tasks such as chart review and outcomes analysis, (9) Forwarding information to your insurance carrier in order to receive payment on claims (after obtaining your Medical Records Release and Insurance Assignments), and/or (10) Sharing information to insurers and other entities involved in your workers’ compensation case as authorized by law.

Eby Dental Care may also use or disclose your personal health information without prior authorization for public health purposes, for auditing purposes, for research studies and for emergencies. We also provide information when required by law.

In any other situation, Eby Dental Care’s policy is to obtain your written authorization before disclosing your personal information. If you provide us with a written authorization to release information for any reason you may later revoke that authorization to stop future discloses at any time.

Patient’s Individual Rights

You have the right to review or obtain a copy of your personal health information at any time. You have the right to request that we correct any inaccurate or incomplete information in your records. You also have the right to request a list of instances where we have disclosed your personal health information for reasons other than treatment, payment or other related administrative purposes.

You may request in writing that we not use or disclose your personal health information for treatment, payment and administrative purposes except when specifically authorized by you, when required by law or in an emergency circumstance. Eby Dental Care will consider all such requests on a case-by- case basis, but the practice is not legally required to accept them

SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )
Yes, I acknowledge and understand the Hipaa Notice of Eby Dental Care.

HIPAA NOTICE & FINANCIAL POLICY

The undersigned acknowledges receipt of Eby Dental Care’s HIPAA Notice and Financial Policy

(Please click below to draw/upload sign)
(Your IP Address : )
Yes, I acknowledge and understand the Hipaa Notice & Financial Policy of Eby Dental Care.
Thank you for visiting Eby Dental Care. We want your visit to be pleasant and comfortable. Please help us by completing this form
Patient Information

Personal Details

Title:     First Name:     Middile Intial:     Last Name:    
Date Of Birth:     Social Security Number:    
Gender:     Marital Status:    

Address

Street Address:     City:     State:     Zip:    
Home Phone:     Cell Phone:     Work Phone:    
Email Address:    

Emergency Contact Information

Name:     Relation:    
Home Phone:     Work Phone:    
Address:     City:     State:     Zip Code:    

Professional Information

Employer Name:     Position:    
Employer Address:     City:     State:     Zip Code:    

Primary Insurance and/or Person Responsible for Payment

Name:     Date of Birth    
Social Security Number:     Relationship to patient:    
Street Address     City:     State:     Zip Code:    
Employer Name:    
Home Phone:     Cell Phone:     Work Phone:    
Employer's Address:     City:     State:     Zip Code:    
Occupation :    
Insurance Company :     Telephone:    
Group Number     Contract Number    

To the best of my knowledge, the information above is correct. I realize that this office will provide insurance billing and assist with insurance benefits to the best of it’s knowledge. However, all charges for services are ultimately my responsibility.

 
  
 
Signature (Parent’s if minor) DATE & IP ADDRESS
Do You have Primary Insurance? Yes No

Secondary Insurance Information

Name:     Date of Birth    
Social Security Number:     Relationship to patient:
Street Address     City:     State:     Zip Code:    
Home Phone:     Cell Phone:     Work Phone:    
Employer Name:    
Employer's Address:     City:     State:     Zip Code:    
Occupation :    
Insurance Company:     Telephone:    
Group Number:     Contract Number    

To the best of my knowledge, the information above is correct. I realize that this office will provide insurance billing and assist with insurance benefits to the best of it’s knowledge. However, all charges for services are ultimately my responsibility.

 
  
 
Signature (Parent’s if minor) DATE & IP ADDRESS
Do You have Secondary Insurance? Yes No
Medical History
Physicians Name     Telephone     Date of last physical    
General Health Excellent Good Fair
Are you under current medical treatment?
Yes
No
Details:
Are you currently taking any medications or herbal supplements?
Yes
No
Medications (prescription and non-prescription) vitamins, supplements:
Do you have allergies or adverse reaction to drugs?
Yes
No
List drug and reaction:
Have you ever taken I.V. or oral Bisphosphonates for bone density such as Fosamax, Actonel, Boniva, Aredia, Zometa or Bonefos
Yes
No
Are you on a special diet?
Yes
No
Have you lost or gained more than 10 pounds in the past year?
Yes
No
Do you use any form of tobacco?
Yes
No
Cigarettes Cigars Snuff Chew
Are you interested in quitting?
Yes
No
Do you consume alcohol?
Yes
No
how much per week on average:
Are you a woman?
Yes
No
Pregnant Nursing On hormone therapy
On birth control medication Trying to get pregnant?
Do you have or have you ever had any of the following ?
Rheumatic Fever Diabetes/FAMILY HISTORY
Respiratory Disease High Blood Pressure/FAMILY HISTORY
Heart Murmur Stroke/FAMILY HISTORY
Heart Disease/FAMILY HISTORY Epilepsy
Head Injuries Other Heart Ailment
Caffeine Dependency Chemo/Radiation Therapy
Psychological/Psychiatric Mitral Valve Prolapse
Artificial Joints Cancer
Liver Disease Bleeding Problems
HIV or AIDS Blood Transfusion
Kidney Disease/FAMILY HISTORY Latex Sensitivity
Arthritis/FAMILY HISTORY Organ Transplant
Major Operations Venereal Disease INCLUDES HPV+
Have you ever been told you need Antibiotics prior to treatment Hepatitis
Gum Disease/FAMILY HISTORY Pacemaker
Dementia/Alzheimers/FAMILY HISTORY Do you have a disease or condition not listed
Details :
Details:
Dental History
What is your immediate dental concern?    
Do you have dental pain now? Yes No

When was your last dental visit?     What was done at that appointment?     When was your last cleaning and exam?     Were x-rays taken?     Who was your previous dentist?     City     Phone     What influenced you to change dentists?    
Are any of your teeth sensitive to hot or cold? Yes No
Biting or chewing pain? Yes No


Please check if you have or have ever had:

Unfavorable dental experiences Yes No Difficulty opening your mouth widely Yes No
Dental fears Yes No Stiff or sore head, neck & shoulder muscles Yes No
Preference for no dental anesthetic Yes No Do you wake up with tooth or jaw pain Yes No
Tension headaches Yes No Clench or grind your teeth Yes No
Jaw clicking or popping Yes No Bleeding gums Yes No
Any oral appliances Yes No Any removable teeth Yes No
Family history of diabetes Yes No Part of your mouth sensitive to temperature Yes No
Lumps or bumps on head or neck Yes No Dry mouth Yes No
Unpleasant taste or odor in your mouth Yes No Do you have a sugar or soda pop habit Yes No
Viral infection or cold sores Yes No Noticed loose teeth or a change in your bite Yes No
Orthodontic treatment (braces) Yes No Jaw problems (TMJ) Yes No
Parents who have lost teeth or had gum disease Yes No How often do you: Brush Yes No
Problems with effectiveness of or bad reactions to dental anesthetic Yes No How often do you: Floss Yes No
Breath through your mouth while awake or asleep Yes No Habitual chewing of hard substances ie, ice, popcorn kernels Yes No


How important is it for you to keep your teeth for the rest of your life
Not Important 1 2 3 4 5 6 7 8 9 10 Very Important

How do you rank your smile
Unpleasant 1 2 3 4 5 6 7 8 9 10 Beautiful


What would you change about your smile if you could?     What is your biggest concern about having dental treatment?    

To the best of my knowledge, the information above is correct. I realize that this office will provide insurance billing and assist with insurance benefits to the best of its knowledge. However, all charges for services and collection costs for untimely payments are ultimately my responsibility.

Treatment Authorization

The information on this page is correct to the best of my knowledge. I authorize and give consent to perform dental services agreed between doctor and patient and/or parent or guardian to be necessary or advisable including the use of local anesthesia and other medication as indicated. I certify to the above statements regarding my medical condition.

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

General Consent

1. During the course of treatment, I may undergo procedures in all phases of dentistry including periodontics (gum treatment and surgery), oral surgery, endodontics (root canals), fixed and removable prosthodontics (crowns, bridges, and dentures), implant dentistry, restorative dentistry, temporomandibular disorder treatment, sleep apnea treatment, oral pathology, pediatric dentistry, and radiography. Some of the procedures may be performed by a dental profession other than the dentist including a dental assistant or dental hygienist that have been trained to perform certain tasks and is allowable by Florida law.

2. I will provide a thorough and complete medical history, supply a full list of my medications with dosages, and consent to my dentist communicating with my other medical practitioners to inquire about any aspect of my health history.

3. No guarantees can be made about treatment outcomes, restoration longevity, or prognoses. I understand that any branch of medicine, including dentistry, can involve unanticipated results.

4. Payment is due the day of service and I am responsible for the full amount owed regardless of any insurance policy I may or may not have. The practice will help in filling any forms needed for insurance reimbursement and those payments will be given to the patient. There is no guarantee that an insurance company will cover work that may be performed.

5. My treatment plan may change at any time and I will do my best to approach my dental care with optimism and open communication with my dentist, hygienist, and dental office staff.

6. I am welcome to ask questions about any aspects of my dental care and will request information if I am confused or need more information. I am responsible for clarifying any aspects of my treatment that I am unsure about.


Most dental procedures require the use of dental anesthetic or numbing to complete the procedure. I understand that there are risks involved in using anesthetic which include permanent or temporary loss of feeling and or muscle control from nerve damage, pain from injection site including muscle tightness or even muscle damage that may or may not go back to normal, allergic reaction, and any other side effects as
 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

Missed Appointment / Cancellation Policy

Due to the high number of patients requiring dental care, waiting times for appointments can be long. Because of this, we enforce a missed appointment policy to ensure that other patients receive care in a timely manner. Missed appointments and appointments cancelled without 24-hour notice are subject to a cancellation fee of $50.

Recieving Appointment Reminders Via Email and Text

Please check a source in which you would like to recieve appointment reminders.

Email
Text Message
Both Email and Text Message
Email Address(if applicable)
Cell Phone(if applicable)

We use this information to provide you with excellent treatment. We may disclose Patient Health Information (PHI) to third parties that perform services for Eby Dental Care in the administration of your benefits in accordance with HIPAA. These parties are required by law to sign a contract agreeing to protect the confidentiality of your PHI. Your PHI may be disclosed to an affiliate that performs services for Eby Dental Care in the administration of your benefits. Our affiliates do not sell, share or rent our users’ personally identifiable information unless required by law, do not send and e-mail or other communications without user permission, and do not send spam.

 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

HIPAA NOTICE

HIPAA

Health Insurance Portability and Accountability Act

Legal Duty

Eby Dental Care is required by law to protect the privacy of your personal health information, provide this notice about our information practices and follow the information practices that are described herein.

Uses and Disclosures of Health Information

Eby Dental Care uses your personal health information primarily for treatment, obtaining payment for treatment, conducting internal administration and evaluating the quality of care that we provide. Some examples of uses of your personal health information may include, but are not limited to, the following: (1) Contacting you by telephone/mail and leaving a message if necessary to provide or obtain information regarding appointments, your treatment, your patient account, treatment alternatives or other health related benefits and services that we offer, and/or company news; (2) Obtaining information from your referral source in order to schedule an appointment and to verify/authorize insurance benefits, (3) Announcing your arrival to the therapist in an area where others may hear the information, (4) Calling out your name in the waiting area, (5) Placing your encounter form and/or medical record in a slot beside your treatment room door, (6) Treating you in an open area where conversations between you and your therapist may be overheard buy other patients and staff, (7) Sharing information as needed with other health care providers involved in your care, (8) Performing quality assurance tasks such as chart review and outcomes analysis, (9) Forwarding information to your insurance carrier in order to receive payment on claims (after obtaining your Medical Records Release and Insurance Assignments), and/or (10) Sharing information to insurers and other entities involved in your workers’ compensation case as authorized by law.

Eby Dental Care may also use or disclose your personal health information without prior authorization for public health purposes, for auditing purposes, for research studies and for emergencies. We also provide information when required by law.

In any other situation, Eby Dental Care’s policy is to obtain your written authorization before disclosing your personal information. If you provide us with a written authorization to release information for any reason you may later revoke that authorization to stop future discloses at any time.

Patient’s Individual Rights

You have the right to review or obtain a copy of your personal health information at any time. You have the right to request that we correct any inaccurate or incomplete information in your records. You also have the right to request a list of instances where we have disclosed your personal health information for reasons other than treatment, payment or other related administrative purposes.

You may request in writing that we not use or disclose your personal health information for treatment, payment and administrative purposes except when specifically authorized by you, when required by law or in an emergency circumstance. Eby Dental Care will consider all such requests on a case-by- case basis, but the practice is not legally required to accept them

 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS
Yes, I acknowledge and understand the Hipaa Notice of Eby Dental Care.

HIPAA NOTICE & FINANCIAL POLICY

The undersigned acknowledges receipt of Eby Dental Care’s HIPAA Notice and Financial Policy

 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS
If not Patient, Relationship to Patient
Yes, I acknowledge and understand the Hipaa Notice & Financial Policy of Eby Dental Care.

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