Click on Calendar, type the year 'YYYY' and pick the month & date.

Patient Registration Information

Please answer all question, so that we may diagnose your oral health as accurately as possible. All information will be kept strictly confidential.
Thank You..!

*Patient Name:

Last name

Mid name

First name

Nick Name:

Birthday:

Age:

Gender: Male Female

Social security#:

*Mailing Address:

				City
State		Zip		APT#

*Home phone #:	()- -	Cell #:	()- -
Text #:	()- -	Phone Carrier:

*Email Address:

Whom may we Thank for referring you?

Person responsible for Payment:

Patient's Employer Details-

Occupation:

Employer:

Work phone #:

()- - -

Spouse Information-

His / Her name:

Birthday:

Social security#:

Occupation:

Employer:

Work phone #:

()- - -

Emergency Contact Details, Whom may We Contact?

His / Her name:

Relationship:

Work phone #:

()- - -

Home phone #:

()- -

Insurance Information

Primary Insurance Details -

Employee:

Employer:

Insurance Co.:

Patient's ID No:

Group#:

Secondary Insurance Details-

Employee:

Employer:

Insurance Co.:

Patient's ID No:

Group#:

Dental History

Chief dental concern:

Are you nervous about having dental treatment?	Yes No
Have you ever had a bad dental experience?	Yes No
Do you have difficulty or pain when opening (yawning)?	Yes No
Does your jaw is stuck, locked or "go out"?	Yes No
Difficulty/ pain when chewing, talking, or using your jaws? Teeth?	Yes No
Do you have noises in your jaw joints?	Yes No
Pain about the ears, temples or cheeks?	Yes No
Does your bite feel uncomfortable or unusual?	Yes No
Have you had a recent injury to your head/jaw?	Yes No
Have you been treated for a jaw joint problem?	Yes No
Do your teeth ever feel loose?	Yes No
Does food catch in-between your teeth?	Yes No

How many times do you brush per day?

Floss?

Any difficulty chewing your food?	Yes No
Have you ever had periodontal disease?	Yes No
Are you teeth sensitive to cold/heat/etc.?	Yes No
Have you ever had an artificial joint placed?	Yes No
Do you have frequent Headaches?	Yes No
Do you use a CPAP machine?	Yes No
Are you happy with the way your smile looks?	Yes No

If not, what would you change?

Health History

Are you having any pain or discomfort at this time?	Yes No
Do you smoke or use tobacco in any form?	Yes No
Have you been hospitalized in the past 2 years?	Yes No
Have you been under the care of a medical doctor during the past 2 years?	Yes No

Physician’s Name:

Telephone #:

()- -

Address:

				City
State		Zip		APT#

Are you currently taking any medications/drugs? Yes No

If yes, please list:

List medications:

Women: Are you pregnant? Yes No

Please list any serious medical condition(s) that you have/had:

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

Antibiotics

Aspirin

Codeine

Latex

Metals/ Jewelry

Local/ Dental Anesthetic

Are you aware of being allergic to any other medications or substances?

Yes No

If yes, please list:


*	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. I give permission to Downriver Smiles to use any photos taken for lecturing, marketing, and continuing education purposes.

Your Smile Survey

Answer these few questions as honestly as you can. Your dentist will help you find out how Lumineers can give you a beautiful, white smile, the one you have always wanted in just 2 easy dentist visits!

1.	Do you like the appearance of your smile?	Yes No
2.	Do you like the appearance of your teeth?	Yes No
3.	Do you like the color of your teeth?	Yes No
4.	Do you have spaces between your teeth that you don't like?	Yes No
5.	Do you like the size and shape of your teeth?	Yes No
6.	Are there old filling or dental work you don't like looking at?	Yes No

7.	What would you like to change the most about the appearance of your teeth?

Financial Policy

Ensuring that our patients receive high quality care is the goal of our practice! So that we can take every necessary precaution when providing excellent dental care, please notify us of any change in your medical history. Also, please inform us of any change in name, address, phone number, marital status, employment, or insurance coverage.

Payment in full is due at time of dental treatment to help maintain the practice’s level of excellence. For large procedures, you may pay ½ on the date treatment is started and the balance in full when completed. We are pleased to offer the following payment options:

Cash or Check Visa or MasterCard

Care Credit –

no down payment, no annual fee, no interest option, and extended payment plans available

For patients with dental insurance, you must provide us with current copy of your dental insurance card. A business assistant will verify your dental coverage and give you a breakdown of your benefits. We will also file your insurance forms at no charge.

At each dental appointment, you are required to pay your insurance plan’s deductible and estimated co-payment. Please be aware that we are only capable of approximating your portion due to the large number of insurance companies and to their periodic changes within their contracts. We cannot guarantee what your insurance company will pay; however, we can submit a pre estimate to your insurance company before any major treatment is done.

You and your dental insurance company have an agreement and Downriver Smiles is not involved in this agreement. Because of this fact, if your dental insurance company fails to honor our request for payment, then any balance after 60 days becomes your responsibility.

Thank you for choosing us for your dental care needs. We take pride in our ability to provide the best dental care for your dental care for our family of patients!


*	I have read, understand, and agree to the above financial policy.

Note: Most companies will not pay for composites (while fillings) on posterior teeth, instead, they will pay their allowance for an amalgam (silver filling). The patient is responsible for the difference. Please keep this in mind, as Downriver Smiles does not do amalgam fillings.

Statement Of Privacy Practices

Protecting Your Personal Healthcare Information
we use and disclose the information we collect from you only as allowed by the health insurance portability and accountability act and the State of Washington. This includes issues relating to your treatment, payment, and our health care operations. Your personal health information will never be otherwise given to anyone – even family members – without your written consent. You, of course, may give written authorization for us to disclose information to anyone you choose for any purpose.
Our offices and electronic systems are secure from unauthorized access and our employees are trained to make certain that the confidentiality of your records is always protected. Our privacy policy and practices apply to all former, current, and future patients, so you can be confident that your protected health information will never be improperly disclosed or released.

Collecting Protected Health Information
We will only request personal information needed to provide our standards of quality health care, implement payment activities, conduct normal health practice operations, and comply with the law. This may include your name, address, telephone number(s), social security number, employment data, medical history, health records, etc. while most of the information will be collected from you; we may obtain from third parties if deemed necessary. Regardless of the source, your personal information will always be protected to the full extent of the law.

Disclosure of Your Protected Health Information
As stated above, we may disclose information as required by law. We are obligated to provide information to law enforcement and governmental offices under certain circumstances. We will not use your information for marketing purposes without your written consent.
We may use and/or disclose your health information to communicate reminders about your appointments including voicemail messages, answering machines and post cards.

Patient Rights
You have a right to request copies of your healthcare information. All such requests must be in writing. We may charge you for copies in an amount allowed by law. If you believe your rights have been violated, we urge you to notify us immediately. You may also contact the U.S. Department of Health and Human Services.

Additional Disclosure Authority
In additional to allowable disclosures describes above, I hereby specifically authorized disclosure of my protected health care information to the persons below.

Any member of my immediate family	Yes No
Spouse only	Yes No
Other (please specify):
Name of Patient or Personal Representative sign below: