Dentist Chicago - Dental Educational Videos

Why Choose Us

Interest Free Payment Plans
State-of-the-Art Technology
Modern Office & Guest
Amenities
Snoring & Sleep Apnea
Treatment
Cosmetic Dentistry & Botox
Six Month Braces & Invisalign
Dental Implants & Sedation
Convenient Hours / Location

Memberships

New Patient Registration

Please note that it is important to fill in all the fields before submitting. Thank you.

All information is kept strictly confidential. We cannot share any information you give us to a third party without your approval.

About You	Print blank form to fill by hand

Patient Name :

*Last Name

Middle Name

*First Name

Preferred Name :

*Date of Birth :

Social Security # :

*Home Address :

	*City:		*State:
	*Zip:		APT#:

*Home Phone # :

() - -

Work Phone # :

() - - -

Cell Phone # :

() - -

*Email :

Employer :

Occupation :

Emergency Contact

Last Name:

First Name:

Relationship

Home Phone # :

() - -

Work Phone # :

() - - -

Cell Phone # :

() - -

Preferred Method of Contact : Phone Call Text Email

Dental Benefit Information

Dental Benefits Company: Toll Free Phone Number:

() - -

Are you the subscriber? Yes No

Group Number:

Subscriber ID No (may be SSN) :

Medical Insurance Information
Primary Insurance
Insurance Company :	Phone Number : () - -
Subscriber's Name :	Group # :
Date of Birth :
Secondary Insurance
Insurance Company :	Phone Number : () - -
Subscriber's Name :	Group # :
Date of Birth :

How Did You Hear About Us? (Please select all that apply)
Through a friend or family member. What is their Name?
	First Name:	Last Name:
Through our TV commercial On Comcast On RCN
Through my dental benefits
On the Internet Google Yahoo Yelp CitySearch Facebook Emergency Dentist 24/7
Other Please Describe :

Health History
Physicians Name :	Phone # : () - -

Are you currently under this physicians care?	Yes No
If Yes, What is the purpose of the current care being provided?
Do you have heart disease or a heart problem?	Yes No	Do you have a family history? Yes No
If Yes Please Describe :

Have you ever had or do you currently have any of the following conditions?
Bleeding Problems	Yes No	Breathing Problems	Yes No
Cancer/Radiation Treatment	Yes No	Weakness & fatigue	Yes No
High/Low Blood Pressure	Yes No	High Cholesterol	Yes No
Excessive hunger	Yes No	Excessive thirst	Yes No
Slow healing of cuts	Yes No	Bad breath	Yes No
Organ Transplant	Yes No	HIV / AIDS	Yes No
Joint Replacement	Yes No	Hepatitis	Yes No
Psychiatric Treatment	Yes No	Stroke	Yes No
Obesity	Yes No	Frequent Urination	Yes No
Unexplained weight loss	Yes No	Acid Reflux (GERD)	Yes No
		Treatment :
MyoFacial Pain	Yes No
Treatment :
Headaches :
Tension Headaches	Yes No	If Yes Treatment :
Migraine Headaches	Yes No	If Yes Treatment :
Morning Headaches	Yes No	If Yes Treatment :
Snoring and Sleep Apnea :
Snoring	Yes No	If Yes Treatment :
Sleep Apnea	Yes No
Restless sleep	Yes No	Loss of energy	Yes No
Excessive daytime sleepiness	Yes No	Dry or sore throat	Yes No
Weight gain	Yes No	Using CPAP	Yes No
Had Sleep Test in Last 3 Years?	Yes No
Have a Copy of the Sleep Test Result? Yes No
Depression, irritability or difficulty concentrating Yes No
Diabetes :
Diabetes	Yes No	If Yes Is it under control?	Yes No
Family History of Diabetes	Yes No
Are you prone to diabetic complications? Yes No
How do you monitor your blood sugar?
Who treats your diabetes?

Any other medical conditions, please describe :
Has a physician or dentist ever recommended you take antibiotics before dental treatment?			Yes No
Are you currently using Blood Thinners or have you ever used them in the past? Yes No
Do you now or have you ever used the following : Cigarette Cigar Pipe Chew
If so, How much per day? How many years? If you quit, list what year

Are you allergic or have you had a bad reaction to any of the following?
Local anesthetic (Novacaine) :	Yes No	Penicillin :	Yes No	Latex :	Yes No

Anything else Please describe:
Do you get regular exercise?	Yes No

What medications are you taking right now and for what condition?
Include prescription and over the counter : Example: Prilosec for acid reflux
Medication	Condition
for
for
for
for
for

Female Patients:

Are you pregnant?

Yes No

Are you nursing?

Yes No

Are you currently taking birth control?

Yes No

Are you menopausal?

Yes No

Are you currently taking any medication to increase bone density?

Yes No

Dental History
Why are you here today?
Who was your last dentist? Dr.
When was the last time you saw a dentist?
Why did you decide to change dentists?
Have you ever had an unpleasant dental experience? Yes No
If Yes Please Describe:
How is your current dental health? Good Average Needs Improvement Not sure
Do your gums bleed when you brush or floss? Never Sometimes Almost Every Time

TMJ Disorder

Yes No

How would you describe your parent's dental health?
What is the level of dental treatment are you interested in?
Emergency or Urgent care needs where pain exists or something is wrong.
Preventative care to stop problems before symptoms occur.

What do you want to improve with your smile and health?
Whiteness	Replace Missing Teeth	Staining/Discoloration
Straighten teeth	Teeth Grinding & Clenching	Existing Dental Work
Smile Makeover / Veneers	Dry Mouth	Chipping or Cracking
Bad Breath	Stop Snoring	Sleep Apnea
Pain/Discomfort	Reduce Headaches	Headache treatment
Replace my CPAP	TMJ treatment
Replace Denture/Partial Denture
Remove unsightly silver/black mercury fillings
Stop Choking and Gasping During Sleep
Botox ® Cosmetic to reduce expression lines/wrinkles
Botox ® Therapeutic for TMD, clenching and headache treatment
Gum Health/Appearance/Smile Line (Do you see enough/too much of your gums?)
Other:
If you could change anything about the appearance of your smile, what would it be?

General Office Information
With your permission, we may take x-rays and photographs to evaluate your dental health. Video and audio recording devices may be used to monitor consultations and treatment to ensure a high quality experience for all of our patients. We will not share any of your personal information with anyone outside of this office without your consent.
24-Hour Cancellation Policy
When we reserve time for your appointment, we make room in our schedule so we may devote our time and focus our efforts on serving your needs. Late cancellations mean we have empty time in our schedule when we could have been helping another patient. There is a $25 per hour charge for reserved appointments, broken or changed by the patient without 24 hour notice.


*	I understand and agree with the Office Policies of Smile More Today.

Payment Plans / Financing / Credit
How will you be paying for your treatment today and in the future?

Are you interested in learning about flexible third party financing plans available to you? Yes No
Are you interested in exploring interest free financing? Yes No

Financial Policy
You are responsible for the total fee for services performed at this office. Cash and all major credit cards are accepted as payment for services at Smile More Today. Checks are accepted with a valid credit card on file.
If we receive payment after 21 days from your benefits company, it will be applied to your account and you will receive a statement from us informing you of any credit generated by the payment.
After 90 days from the date of service, any unpaid balance will be turned over to a collection agency. This is our standard policy for all delinquent accounts. Once an account is sent to collections, you must pay the collection agency. You will no longer be able to pay us directly for the balance.

In accordance with HIPAA, I agree to Smile More Today use and disclosure of my protected health information to my benefits company. I understand that my benefits company will send payment directly to Smile More Today unless prior arrangements have been made.

It is each patient responsibility to make a determination if they have active insurance coverage. Patients that receive treatment and later find out they are not active are responsible for the full amount of services provided.

For patients who choose to have us bill insurance and are unwilling to pay the full amount at the time of service, and would rather wait for reimbursement, we require a credit card on file in the event that the insurance company fails to pay or insufficient payment is received. At the receipt of insurance reimbursement and explanation of benefits the patient will be informed that the remaining balance will be placed on their card before the card is charged.

We are in-network with select PPO dental benefit plans. We will bill the benefit plan on behalf of the patient once the service has been started.

In the unfortunate event of failure to pay outstanding bills in a timely manner we will reserve the right to turn the amount over to a credit agency and/or withhold services.


*	All bounced checks will incur an additional fee of $35.

*	I agree to pay all collection costs and reasonable attorney's fees incurred in attempting to collect on the account balance.

*	I understand and agree with the Financial Policies of Smile More Today.

*	I understand this office participates in the Cook County and Lake County Bad Check Restitution Program.

You May Download a Copy of Our "Notice of Privacy Practices Form" Here

Download Free Adobe Acrobat Reader Now

Acknowledgement Of Receipt Of Privacy Practices Notice
Purpose: This form is used to obtain acknowledgement of receipt of our Notice of Privacy Practices or to document our good faith effort to obtain that acknowledgement.

* I ,
have received a copy/explanation of this office’s Notice of Privacy Practices.
Relationship to Patient Self or Other :


*Signature of patient, parent or guardian	Date	Relationship to patient

Smile More Today dental wellness center Located at 250 Center Drive, Suite 202, Vernon Hills, IL 60061 . Phone: 224-324-3151. www.smilemoretoday.com