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Arctic Oral Surgery

Patient Registration Packet

Patient Information

Name

Date of Birth

Gender

Female Male

Mailing Address

City / Zip

Email Address

May we email you?

Yes No

Home Phone / Cell Phone

May we text you?

Yes No

Dentist that referred you?

Who is your medical doctor?

Insurance/Billing Information

Do you have Insurance?

Yes No

Primary Insurance

Is this insurance coverage

Medical Dental Both

Company

ID# / Group#

Insured Name (parent, spouse, etc.)

SSN / DOB

Relation to Patient / Employer

Insured Address (parent, if different)

City / State / Zip

Secondary Insurance

Is this insurance coverage

Medical Dental Both

Company

ID# / Group#

Insured Name (parent, spouse, etc)

SSN / DOB

Relation to Patient / Employer

Insured Address (parent, if different)

City / State / Zip

Minor Patients (Under 18)

The parent or guardian accompanying the minor to the office is responsible for any charges incurred and any payment due at the time of service. In the case of multiple guardians (divorce or separation) the financial responsibility becomes that of the guardian who accompanies the patient to their appointment. If insurance coverage is under a guardian not present at the time of service, the information pertaining to that coverage (address, SSN, ID#) is required to bill the insurance.

Parent or Guardian Name

Address (if different than minor)

City / State / Zip

Phone Number / Email

Emergency Contact

Name

Phone / Relation

Name

Phone / Relation

ACKOWLEDGEMENT OF RECEIPT OF FINANCIAL POLICY

I hereby certify that I have read and been provided a copy of Arctic Oral Surgery’s financial policy, I further certify that I am the patient or legally authorized by the patient to accept the terms of this Financial Policy. A photocopy of this document has the same effect as an original.

Print Name of Patient or Patient’s Legally Authorized Representative

Signature of Patient or Patient’s Legally Authorized Representative

Click to Sign

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

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

A complete description of how your medical and dental information will be used and disclosed by Arctic Oral Surgery is in our NOTICE OF PRIVACY PRACTICES, which you should read before signing this Acknowledgment.

A copy of Arctic Oral Surgery Notice of Privacy Practices was provided to you.

Print Name of Patient or Patient’s Legally Authorized Representative

Signature of Patient or Patient’s Legally Authorized Representative

Click to Sign

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

I authorize Arctic Oral Surgery to share information with…

None/Do not share my information with anyone besides myself or my insurance company.

Yes No

Name

Phone/Relation

Name

Phone/Relation

Name

Phone/Relation

HEALTH HISTORY

Answer all questions by checking Yes or No

All responses are kept confidential

Are you in good health?

Yes No

Has there been any change in your general health in the past year?

Yes No

Date of last physical exam

Are you now under a physician’s care for a particular problem

Yes No

Have you ever had any serious illnesses, operations or hospitalizations?

Yes No

HEIGHT / WEIGHT

Do you smoke or chew tobacco?

Yes No

How much per day?

Is there any past history of Alcohol, Chemical Dependency or Emotional Disorder that may affect the care we provide you?

Yes No

Have you had any serious problems associated with any previous dental treatment?

Yes No

Have you or an immediate family member had any problems associated with intravenous anesthesia?

Yes No

Do you have any other disease, condition or problem not listed that you think the doctor should know about? If yes, please list

FEMALES ONLY

Are you pregnant or is there any chance that you might be pregnant?

Yes No

Are you nursing?

Yes No

Are you using oral contraceptives?

Yes No

Date of last menstrual cycle?

ARE YOU TAKING OR HAVE YOU EVER TAKEN BONE DENSITY MEDS, RANKL INHIBITORS OR BISPHOSPHONATES?

(Such as Denosumab, Fosamax, Boniva, Actonel, IV-Zometa, Aredia, Reclast or Evista in the past 12 years?)

If yes, please list

Print Patient Name

Sign & Date (if patient is a minor parent sign)

Click to Sign

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

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Main Header

Arctic Oral Surgery

Patient Information

Patient Information

Insurance/Billing Information

Insurance/Billing Information

Primary Insurance

Secondary Insurance

Minor Patients (Under 18)

Ackowledgement Of Receipt Of Financial Policy

ACKOWLEDGEMENT OF RECEIPT OF FINANCIAL POLICY

Click to Sign

Acknowledgement of Receipt of Notice of Privacy Practices

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Click to Sign

Health History

HEALTH HISTORY

DO YOU HAVE OR HAVE EVER HAD

ARE YOU USING ANY OF THE FOLLOWING

ARE YOU ALLERGIC TO OR HAVE YOU HAD AN ALLERGIC REACTION TO:

FEMALES ONLY

ARE YOU TAKING OR HAVE YOU EVER TAKEN BONE DENSITY MEDS, RANKL INHIBITORS OR BISPHOSPHONATES?

Click to Sign

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Main Header

Arctic Oral Surgery

Patient Information

Patient Information

Insurance/Billing Information

Insurance/Billing Information

Primary Insurance

Secondary Insurance

Minor Patients (Under 18)

Ackowledgement Of Receipt Of Financial Policy

ACKOWLEDGEMENT OF RECEIPT OF FINANCIAL POLICY

Click to Sign

Acknowledgement of Receipt of Notice of Privacy Practices

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Click to Sign

Health History

HEALTH HISTORY

DO YOU HAVE OR HAVE EVER HAD

ARE YOU USING ANY OF THE FOLLOWING

ARE YOU ALLERGIC TO OR HAVE YOU HAD AN ALLERGIC REACTION TO:

FEMALES ONLY

ARE YOU TAKING OR HAVE YOU EVER TAKEN BONE DENSITY MEDS, RANKL INHIBITORS OR BISPHOSPHONATES?

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.

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