Patient RegistrationWe streamline your first visit to our office by providing an opportunity to complete our patient forms online prior to your appointment. Please fill out the patient registration form below to complete your paperwork.Patient Registration Please complete all information that applies to you. Thank you.1 Patient Info2 Responsible Party3 Medical History4 Financial Policy5 Photo ReleasePatient InformationFirst NameLast NameHow do you wish to be addressed?Date of BirthEmail Address Social Security NumberYour personal data is secure and encrypted.Patient's Address Address Marital StatusMarriedSingleDivorcedGenderMaleFemaleFull Time Student?YesNoWhich is your primary phone number?Cell/MobileWorkHomeCell/MobileWork PhoneHome PhoneEmployment and Insurance InformationEmployerOccupationDental Insurance Co.GroupIs the patient covered by another dental insurance?YesNoSecondary Dental InsuranceHow did you hear about our practice? Yellow Pages Google Facebook Insurance provider Drove past office Friend/Family/AssociateWhom may we thank for your referral? Spouse, Parent, or Responsible Party(if other than parent)Is the patient the responsible party?YesNoResponsible Party NameResponsible Party Address Street Address Which is your primary phone number?Cell/MobileWorkHomeCell/MobileWork PhoneHome PhoneEmail Social Security NumberYour personal data is secure and encrypted.EmployerOccupationDental Insurance Co.GroupNearest RelativeName of Nearest RelativeRelative's Address Street Address Primary phone numberCell/MobileWorkHomeCell/MobileWork PhoneHome PhoneAuthorizationI authorize the dentist or designated staff to take x-rays, study models, photographs and other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of dental needs. Upon such diagnosis, I authorize the doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.I agree to the use of anesthetics, sedatives and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.I authorize the release of any information concerning my (or my child’s) health care, advice, and treatment provided for the purpose of evaluating and administering claims for insurance benefits. I authorize the release of any information concerning my (or my child’s) health care, advice, and treatment to my primary care physician, medical specialist or dental specialist to enable proper coordination of care for my oral and overall health.I understand that my dental care insurance carrier or payer of my dental benefits may pay less than the actual bill for services. I understand that I am financially responsible for payments in full of all accounts. By signing this statement, I revoke all previous agreements to the contrary and agree to be responsible for payments of services not paid, in whole or in part, by my dental care payer.I attest to the accuracy of the information on this page. I agree to these terms. Medical HistoryAlthough dental personnel primarily treat the area in and around your mouth, your is mouth is part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.Are you under a physician's care now?YesNoPlease explain:Have you ever been hospitalized or had a major operation?YesNoPlease explain:Have you ever had a serious head or neck injury?YesNoPlease explain:Are you taking any medications, pills, or drugs?YesNoPlease explain:Do you take, or have taken, Phen-Fen or Redux?YesNoPlease explain:Are you on a special diet?YesNoPlease explain:Do you use tobacco?YesNoPlease explain:Do you use controlled substances?YesNoPlease explain:Are you pregnant or trying to get pregnant?YesNoTaking oral contraceptives?YesNoNursing?YesNoAre you allergic to any of the following? Aspirin Penicillin Codeine Acrylic Metal Latex Local anesthetics OtherPlease explain:Do you have, or have you had, any of the following?Please select all that apply. AIDS/HIV Positive Alzheimer’s Disease Anaphylaxis Anemia Angina Arthritis/Gout Artificial Heart Valve Artificial Joint Asthma Blood Disease Blood Transfusion Breathing Problem Bruise Easily Cancer Chemotherapy Chest Pains Cold Sores/Fever Blisters Congenital Heart Disorder Convulsions Cortisone Medicine Diabetes Drug Addiction Easily Winded Emphysema Epilepsy or Seizures Excessive Bleeding Excessive Thirst Fainting Spells/Dizziness Frequent Cough Frequent Diarrhea Frequent Headaches Genital Herpes Glaucoma Hay Fever Heart Attack/Failure Heart Murmur Heart Pacemaker Heart Trouble/Disease Hemophilia Hepatitis A Hepatitis B or C Herpes High Blood Pressure Hives or Rash Hypoglycemia Irregular Heartbeat Kidney Problems Leukemia Liver Disease Low Blood Pressure Lung Disease Mitral Valve Prolapse Pain in Jaw Joints Parathyroid Disease Psychiatric Care Radiation Treatments Recent Weight Loss Renal Dialysis Rheumatic Fever Rheumatism Scarlet Fever Shingles Sickle Cell Disease Sinus Trouble Spina Bifida Stomach/Intestinal Disease Stroke Swelling of Limbs Thyroid Disease Tonsilitis Tuberculosis Tumors of Growths Ulcers Venereal Disease Yellow JaundiceHave you ever had any serious illness not listed above?YesNoPlease explain:Additional comments:To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status. To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status. Financial PolicyOur practice and team are committed to providing you with the best possible care, and we are pleased to discuss our professional fees with you at any time.Your clear understanding of our Financial Policy is important to our professional relationship. Please ask if you have any questions about our fees, Financial Policy, or your responsibility.All patients must complete our “Patient Registration Form” before seeing the dental professional.Full payment is due at the time of service unless prior arrangements have been made with our treatment coordinator.We accept cash, checks, Visa, and MasterCard.As a courtesy to our patients, we will electronically submit your dental claims to your insurance company. They will reimburse you directly for a percentage of their “usual and customary fee” in accordance with your given policy.Adult PatientsAdult patients are responsible for full payment at time of service.Minors Accompanied By An AdultThe adult accompanying a minor, his/her parents or guardians, are responsible for full payment at time of service.Unaccompanied MinorsThe parents or guardians are responsible for full payment at time of service. Non-emergency treatment will be denied unless charges have been pre-authorized to an approved credit plan or to Visa or MasterCard.InsuranceOur practice provides insurance company billing as a courtesy to our patients. Your dental insurance policy is a contract between you the patient and your insurance company. Our dental team believes in recommending treatment for the sole purpose of optimizing our patients’ dental health. Insurance often does not cover necessary treatment in full. We will gladly submit a preauthorization for your prescribed treatment with your request.Most insurance companies have an annual limitation for the amount of dental services that can be reimbursed within each plan year. If you or your family exceed these annual limitations in any plan year, your insurance company will not reimburse you for the dental services that exceed the particular plan’s limitations. The patient is responsible for monitoring the amount of his/her remaining benefits for any annual benefit period. The patient may not rely upon any information provided by our staff regarding his/her remaining benefit in any such benefit period.If you or your family has more than one dental insurance program, we will assist you in obtaining the maximum benefits available.You, as the patient, are always responsible for the investment you make towards your dental health.Medicare/ Medicaid/ Champus/ Worker’s CompensationIf you are covered by Medicare, Medicaid, Champus, Worker’s Compensation or any other government sponsored program, please discuss your payment situation with our office staff prior to date of service.Delinquent PaymentsIt is our policy to charge finance fees at 1.5% for outstanding patient balances after the balance has been outstanding 30 days. In addition, all payments returned due to non-sufficient funds will be subject to a NSF fee of $25.00.Missed AppointmentsUnless cancelled at least 48 hours in advance, our policy is to charge for missed appointments at the rate of $35.00 per each 30 minutes of missed appointment time. Please help us service you better by keeping scheduled appointments.Thank you for understanding our Financial Policy. Please let us know if you have any questions or concerns. Photo ReleaseI hereby grant permission to Dr. Laura Sheaffer Harkin, to use my photographs in teaching materials used to provide dental continuing education. I acknowledge Dr. Laura Sheaffer Harkin the right to crop or otherwise treat the photograph at her discretion. I also acknowledge that the doctor may choose not to use my photographs at this time, but may do so at their own discretion at a later date. I also understand that once my image is posted on a web site, any computer user, which is beyond the control of Dr. Laura Sheaffer Harkin, can download the image and I will hold her and any of his affiliated offices harmless from any such use or download.I hereby freely and voluntarily consent to the use of my photograph and testimonial as stated above until I revoke this consent in writing.I agree to the preceding statement.YesNo This iframe contains the logic required to handle Ajax powered Gravity Forms.