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ADULT PATIENT INFORMATION

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New patient Registration
Medical History
Medical history
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Patient Registration( * mandatory to fill )

IF APPLICABLE: Are you currently a full-time student?
Yes
No

Please select below

Do You Have Primary Insurance?
Do You Have Secondary Insurance?
I have read the above choices

DENTAL INSURANCE INFORMATION( * mandatory to fill )

POLICY HOLDER :

I hereby authorize & direct payment of the dental benefits to Moore Dental Services, Inc, DBA Dental Development Center. I consent to your use & disclosure of my protected health information as permitted by law. I also agree to make all co—payments and/or deductible payments on the date of service.

SIGNATURE
 
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(Your IP Address : )

Secondary Insurance Company( * mandatory to fill )

POLICY HOLDER :

I hereby authorize & direct payment of the dental benefits to Moore Dental Services, Inc, DBA Dental Development Center. I consent to your use & disclosure of my protected health information as permitted by law. I also agree to make all co—payments and/or deductible payments on the date of service.

SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

MEDICAL HISTORY INFORMATION

3. Are you currently taking any medication?
Yes
No
4. Are you allergic to any medications? If so, please list?
Yes
No
5. Have you ever had a heart murmur or any heart condition?
Yes
No
6. Have you ever been hospitalized or had surgery?
Yes
No
7. Have you ever been told you should pre-medicate prior to dental appointments?
Yes
No
8. Have you been or are you being treated for osteoporosis?
Yes
No
9. Any history of Head/Neck Radiation?
Yes
No

10. Please check any condition, whether condition was in the past or present.

I have answered all the above questions

Consent & Agreements

As a condition of treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from patients for the costs incurred in their care. Financial responsibility on the part of each patient must be determined before treatment. All portions of dental services not expected to be paid by insurance must be paid for at the time services are performed. It is your responsibility to know the limitations of your plan (such as, but not limited to frequency of cleanings, xrays, etc). I understand that any fee estimate for this dental care can only be extended for a period of 90 days from the date of the patient examination. In consideration for the professional services rendered to me by this practice, I agree to pay the charges for the services at the time of treatment. I further agree that the charges for services shall be as billed unless objected to, by me, in writing within the time payment is due. I further agree that a waiver of any breach of any time or condition hereunder shall not constitue a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder. I grant my permission to you or your assignee to telephone me at any and all numbers provided to discuss my account or my child’s treatment.

I have read the above conditions of treatment and payment and agree to their content. All information on this form is accurate and pertinent information has not been excluded. I give my consent to Moore Dental Services for the treatment of this patient. I also acknowledge receipt of a copy of this office’s Notice of Privacy Practices.
SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

As an adult, our office staff needs permission to discuss your treatment and/or account with anyone other than you. Please list names of individuals below who are permitted to have such discussions. If you choose not to grant anyone permission, please type "DECLINE".

SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )
Moore Dental Services * Dr. Brian A Moore * 859-525-0507
Dental Development Center * Dr. Martin J Moore * 859-371-4422
Thank you for visiting MOORE DENTAL SERVICES. We want your visit to be pleasant and comfortable. Please help us by completing this form
ADULT PATIENT INFORMATION
Selected office you visit:
Title: First Name: Middle Initial: Last Name: Preferred Name:
Date Of Birth: Gender: Social Security Number:
Address: City: State: Zip:
Home Phone: Cell Phone: Email:
Who may we thank for referring you?
IF APPLICABLE: Are you currently a full-time student? Yes No
Name of School You Attend:
DENTAL INSURANCE INFORMATION
Primary Insurance Company Name: Phone:
Insurance Co. Address: City
State Zip
Insured ID: Policy Group Number:
Insured’s Name: Date Of Birth: Relationship to patient:
Insured’s Address (if different from the patient):
Employer Name:

I hereby authorize & direct payment of the dental benefits to Moore Dental Services, Inc, DBA Dental Development Center. I consent to your use & disclosure of my protected health information as permitted by law. I also agree to make all co—payments and/or deductible payments on the date of service.

 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS
Do You have Primary Insurance? Yes No
SECONDARY INSURANCE INFORMATION
Secondary Insurance Company Name: Phone:
Insurance Co. Address: City
State Zip
Insured ID: Policy Group Number:
Insured’s Name: Date Of Birth: Relationship to patient:
Insured’s Address (if different from the patient):
Employer Name:

I hereby authorize & direct payment of the dental benefits to Moore Dental Services, Inc, DBA Dental Development Center. I consent to your use & disclosure of my protected health information as permitted by law. I also agree to make all co—payments and/or deductible payments on the date of service.

 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS
Do You have Secondary Insurance? Yes No
MEDICAL HISTORY INFORMATION
Name of Physician
Phone Number of Physician
Are you currently taking any medication? Yes No
If so, please list:
Are you allergic to any medications? Yes No
If so, please list:
Have you ever had a heart murmur or any heart condition? Yes No
Have you ever been hospitalized or had surgery? Yes No
If so, Please explain,
Have you ever been told you should pre-medicate prior to dental appointments? Yes No
Have you been or are you being treated for osteoporosis? Yes No
Any history of Head/Neck Radiation? Yes No
Please check any condition, whether condition was in the past or present.
Asthma Asperger Syndrome Autism Birth Defect
Bleeding Problem Cerebral Palsy Developmental Delay Diabetes
Down Syndrome Epilepsy Head injuries Hearing Impaired
Heart Problem (ANY) Hepatitis High Blood Pressure HIV or AIDS
Jaundice JRA Kidney Problem Latex Allergy
Liver Problem Mental Delay/Disorder Nervous/Emotional Disorder OCD
Pregnancy Prosthetic (artificial) Joint Radiation Treatment Respiratory Problem
Rheumatic Fever Rheumatism Seizures Sensory Issues
Sinus Problem Special Needs Spina Bifida Stroke
Tuberculosis Tumors Ulcers Von Willenbrand’s I
Wheelchair user Other
If other, Please specify
Emergency Contact Name Best Phone #

Consent & Agreements
As a condition of treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from patients for the costs incurred in their care. Financial responsibility on the part of each patient must be determined before treatment. All portions of dental services not expected to be paid by insurance must be paid for at the time services are performed. It is your responsibility to know the limitations of your plan (such as, but not limited to frequency of cleanings, xrays, etc). I understand that any fee estimate for this dental care can only be extended for a period of 90 days from the date of the patient examination. In consideration for the professional services rendered to me by this practice, I agree to pay the charges for the services at the time of treatment. I further agree that the charges for services shall be as billed unless objected to, by me, in writing within the time payment is due. I further agree that a waiver of any breach of any time or condition hereunder shall not constitue a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder. I grant my permission to you or your assignee to telephone me at any and all numbers provided to discuss my account or my child’s treatment.

I have read the above conditions of treatment and payment and agree to their content. All information on this form is accurate and pertinent information has not been excluded. I give my consent to Moore Dental Services for the treatment of this patient. I also acknowledge receipt of a copy of this office’s Notice of Privacy Practices.
 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

As an adult, our office staff needs permission to discuss your treatment and/or account with anyone other than you. Please list names of individuals below who are permitted to have such discussions. If you choose not to grant anyone permission, please type "DECLINE".

Name of Authorized Individuals:
 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

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