PATIENT REGISTRATION

Main Header

Patient Information

Patient's Name

Sex

Male Female

DOB / SS#

Street Address

City / State / Zip

Occupation

Cell Phone / Home Phone

email

May we leave a message

Phone

In case of emergency, notify

Phone

General Dentist

Responsible Party Information (Parent or Guardian)

Responsible Party Name

DOB / SS#

Street Address

City / State / Zip

Phone

Employer Name / Phone

PERSONAL AND MEDICAL HISTORY

Have you ever had or do you presently have any of the following?

PATIENT REGISTRATION / PERSONAL AND MEDICAL HISTORY (cont)

Have you ever been told by your physician that you need to premedicate with an antibiotic before dental treatment due to a medical condition, i.e. heart, artificial joint, etc.?

Yes No

If YES, did you take an antibiotic premedication for today’s visit?

Yes No

Additional Allergies

List ALL medications you are currently taking including herbal remedies:

Any other medical or dental information that you feel the doctor should be aware of?

If applicable:

Are you pregnant?

Yes No

Breast Feeding?

Yes No

Conclusion

Acknowledgment of Financial Responsibility and/or Assignment of Benefits

I agree to pay in full any unpaid balance on my account regardless of insurance. I hereby authorize and direct my insurance company to issue payment for services rendered directly to Central Ohio Endodontics.

PRIVACY POLICY

We collect personal and health information to effectively deliver endodontic services. We treat non-public information about our patients as confidential. All employees are trained and required to protect this information and we maintain the highest standards to safeguard your personal information. If you would like more information about our privacy policy, please ask for a copy of our Healthcare Privacy Statement..

I acknowledge that I have read/have the opportunity to read the privacy policy and authorize the release of any pertinent information relating to my treatment.

Patient/Guardian Signature

Click to Sign

Date:-------------

COE Patient Authorization Form

Authorization to release information to family members

Many of our patients allow family members such as their spouse, significant other, parents or children to call and request the results of tests, procedures and financial information. Under therequirements for HIPAA, we are not allowed to give this information to anyone without the patient’s consent. If you wish to have your medical information, any diagnostic test results or financial information released to any family member, you must sign this form.

You have the right to revoke this consent, in writing, except where we have already madedisclosures in reliance on your prior consent.

I authorize Central Ohio Endodontics to release my records and any information requested to thefollowing individuals:

Name/ Relationship

Authorization regarding messages (Please check all that apply.)

I authorize you to leave a detailed message on my home or cell number regarding appointments.

Yes No

I authorize you to leave a detailed message on my home or cell phone regarding medical treatment, care, test results or financial information.

Yes No

I authorize you to leave a message with anyone who answers the phone.

Yes No

Messages may only be left with (specific individual(s))

Yes No

Patient Signature

Click to Sign

Date:-------------

truForm by PBHS

PATIENT REGISTRATION

Main Header

Patient Information

Patient Information

Responsible Party Information (Parent or Guardian)

Personal and Medical History

PERSONAL AND MEDICAL HISTORY

PATIENT REGISTRATION / PERSONAL AND MEDICAL HISTORY (cont)

Allergies and Medications

Are you allergic or have you reacted adversely to any of the following?

List ALL medications you are currently taking including herbal remedies:

If applicable:

Conclusion

Conclusion

Click to Sign

Patient Authorization Form

COE Patient Authorization Form

Click to Sign

PBHS truForm is best utilized in portrait mode.

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PATIENT REGISTRATION

Main Header

Patient Information

Patient Information

Responsible Party Information (Parent or Guardian)

Personal and Medical History

PERSONAL AND MEDICAL HISTORY

PATIENT REGISTRATION / PERSONAL AND MEDICAL HISTORY (cont)

Allergies and Medications

Are you allergic or have you reacted adversely to any of the following?

List ALL medications you are currently taking including herbal remedies:

If applicable:

Conclusion

Conclusion

Click to Sign

Patient Authorization Form

COE Patient Authorization Form

Click to Sign

PBHS truForm is best utilized in portrait mode.

Please rotate your device to portrait orientation to begin.

You are in Private Browsing mode.

This form requires that you disable private browsing to continue. Please open a new browser window and reload the form.

This form requires that you disable private browsing to continue.
Please open a new browser window and reload the form.