Patient Registration Form Dr. David C. Ashley, DMD & AssociatesPlease tell us about yourself: Preferred Name Gender Male Female Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code SSNDOB MM slash DD slash YYYY Home PhoneWork PhoneCell PhoneE-mail Address Employer Occupation Marital Status Single Married Divorced Widowed Seperated Domestic Partner How did you hear about our office? Do you prefer to be contacted for appointment confirmation via e-mail or phone? InsuranceSubscriber Name Relationship to Patient Subscriber DOB MM slash DD slash YYYY Subscriber SSN/ID Subscriber Employer Insurance Company Name Insurance Company Address Insurance Company PhoneGroup NumberAssignment and ReleaseI understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payments of benefits. I authorize the use of this signature on all insurance submissions.Responsible Party Signature(Required)Relationship Date MM slash DD slash YYYY Consent I consent to the diagnostic procedures and treatment by the dentist necessary for proper dental care.Patient/Guardian Signature(Required)Medical HistoryDo you have a personal physician?(Required) Yes No Physician’s Name(Required) Physician’s Phone(Required)Date of last visit(Required) MM slash DD slash YYYY What is your current physical health?(Required) Good Fair Poor Are you currently under the care of a physician?(Required) Yes No Please explain(Required) Do you use tobacco in any form?(Required) Yes No Have you had any metal rods, pins or implants placed?(Required) Yes No Are you taking any medications?(Required) Yes No Please list each one(Required) Do you or have you taken any medication for osteoporosis?(Required) Yes No Have you ever had any surgical procedures?(Required) Yes No Please list each one(Required) Emergency Contact:Name Relationship Address PhoneConditions Abnormal Bleeding Alcohol Abuse Allergies Anemia Angina Pectoris Arthritis Artificial Heart Valve Asthma Blood Transfusion Cancer Chemotherapy Colitis Congenital Heart Defect Diabetes Difficulty Breathing Drug Abuse Emphysema Epilepsy Facial Surgery Fainting Spells Fever Blisters Frequent Headaches Glaucoma HIV+ AIDS Heart Attack Heart Murmur Heart Surgery Hemophilia Hepatitis A Hepatitis B Hepatitis C High Blood Pressure Joint Replacement Kidney Problems Liver Disease Low Blood Pressure Mitral Valve Prolapse Pace Maker Psychiatric Problems Radiation Therapy Rheumatic Fever Seizures Sexually Transmitted Disease Shingles Sickle Cell Disease Sinus Problems Stroke Thyroid Problems Tuberculosis Ulcers None of the above Allergies Aspirin Codeine Dental Anesthetics Erythromycin Jewelry Latex Metals Penicillin Tetracycline If Female Are you taking Birth Control Pills? Are you pregnant? If yes, how long? I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.Signature(Required)Date MM slash DD slash YYYY Dental HistoryHow may we help you today? When was your last dental: Exam X-rays Cleaning How would you rate your current dental health? Good Fair Poor Why did you leave your previous dentist? CONDITION OF YOUR TEETH:Are you currently experiencing any dental pain/discomfort? Yes No If yes, where and what makes pain/discomfort worse? Do you have cracked, broken or chipped teeth? Yes No Do you have loose or shifting teeth? Yes No Have you prematurely lost any teeth? Yes No Are your teeth sensitive to Hot? Yes No Are your teeth sensitive to Cold? Yes No Are your teeth sensitive to Sweets? Yes No PERIODONTAL HISTORY:Do you have bleeding, swollen or irritated gums? Yes No Have you ever had periodontal/deep cleanings? Yes No Have you ever had periodontal (gum) treatments? Yes No TMJ:Do you have or have you had any pain/discomfort in your jaw joint (TMJ)? Yes No Are you aware of any grinding or clenching of your teeth? Yes No Do you have a night guard? Yes No How often do you wear it? ESTHETICS:Are you happy with your smile? Yes No Are you happy with the color of your teeth? Yes No How would you change your smile? Whiter Straighter Replace metal fillings Replace missing teeth Replace older crowns that don’t match HABITS:Do you smoke or use chewing tobacco? Yes No How much? For how long? How can we make your visit more comfortable today? Signature(Required)Date MM slash DD slash YYYY MedicaI Information Release Form (HIPAA Release Form) Name Date of Birth MM slash DD slash YYYY Release of Information Release of Information I authorize the release of information including the diagnosis, records; examination rendered to me and claims information. This information may be released to: Spouse Spouse Spouse Children Child(ren) Children Other Other Other Release of Information Information is not to be released to anyone. This Release of Information will remain in effect until terminated by me in writing.MessagesPlease call my home HomePlease call work my work WorkPlease call my cell number my cell number CellIf unable to reach me: you may leave a detailed message please leave a message asking me to return your call The best time to reach me is (day and time) Signed Date MM slash DD slash YYYY Witness Date MM slash DD slash YYYY CANCELLATION POLICY: When we make your appointment, we are reserving time for your particular needs. As a courtesy, we contact you to remind you of that reserved appointment. Therefore, we ask that if you must change an appointment, to please contact us at least 48 hours prior to your reserved appointment time. Failure to do so, either by failing to arrive for your appointment or cancelling without proper notice, will result in a charge of $75.OO per hour reserved, per occurrence. By signing below, you acknowledge that you have read and understand our cancellation policy. Signature(Required)Date MM slash DD slash YYYY PAYMENTS: Payment is due at the time services are rendered. We accept cash, check, Visa, MasterCard, Discover, and American Express. We also offer interest free financing through Care Credit for those that qualify. We take the time to explain your dental treatment and your expected out-of- pocket expense. When treatment plans are presented it is an estimate of what we anticipate your dental insurance will cover, based on your policy benefits. In the event your insurance does not cover a procedure or payment is less than anticipated, you are responsible for the balance. If your insurance company does not pay your claim within 60 days from the time services are rendered, you are responsible for the balance. Please keep in mind, your dental benefits are based on a contract between you and your insurance company. You are responsible for accurately reading and understanding your dental coverage. By signing below, you acknowledge that you have read and understand our payment policy. Signature(Required)Date MM slash DD slash YYYY CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.