Patient Registration Form

Today's Date

Patient Registration

Marital Status

Minor

Single

Married

Divorced

Widowed

First Name

Last Name

Street

Apt.

City

State

ZIP

DOB

Gender

Male

Female

Home #

Cell #

Work #

Drivers License/State ID

SS #

Employer

City

State

ZIP

Financially Responsible Party

Title

Relationship to Patient

First Name

Last Name

Street

Apt.

City

State

ZIP

DOB

Gender

Male

Female

Home #

Cell #

Work #

Drivers License/State ID

SS #

Employer

City

State

ZIP

Primary Dental Insurance

Insurance Company

Ins. ID #

Group #

Claims Address

Claims City, State, ZIP

Ins. Phone #

Subscriber's Information

Relationship to Patient

Self

Spouse

Parent

Other

First Name

Last Name

DOB

SS #

Gender

Male

Female

Street Address

City

State

ZIP

Phone #

Employer

Primary Medical Insurance

Insurance Company

Ins. ID #

Group #

Claims Address

Claims City, State, ZIP

Ins. Phone #

Subscriber's Information

Relationship to Patient

Self

Spouse

Parent

Other

First Name

Last Name

DOB

SS #

Gender

Male

Female

Street Address

City

State

ZIP

Phone #

Employer

Student Status

Full-Time

Part-Time

Not in School

School Name

City

State

Do you have secondary insurance?

Yes

Secondary Dental Insurance

Insurance Company

Ins. ID #

Group #

Claims Address

Claims City, State, ZIP

Ins. Phone #

Subscriber's Information

Relationship to Patient

Self

Spouse

Parent

Other

First Name

Last Name

DOB

SS #

Gender

Male

Female

Street Address

City

State

ZIP

Phone #

Employer

Secondary Medical Insurance

Insurance Company

Ins. ID #

Group #

Claims Address

Claims City, State, ZIP

Ins. Phone #

Subscriber's Information

Relationship to Patient

Self

Spouse

Parent

Other

First Name

Last Name

DOB

SS #

Gender

Male

Female

Street Address

City

State

ZIP

Phone #

Employer

Pharmacy Information

Name of Local Pharmacy

Phone #

Street Address

City

State

ZIP

Acknowledgment

Payment is expected at the time services are rendered, unless other arrangements have been made in advance. I understand that I am responsible for payment regardless of whether my insurance pays or not.

Method of Payment

Cash

Check

Credit Card

Signature of Patient/Guardian:

Date:

(If guardian, signature must match responsible party)

Completion Reviewed By

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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HEALTH HISTORY

Patient Information

Today's Date

Full Name

Age

Height

Weight

Referred By

First Name

Last Name

City

State

Phone

Dentist

First Name

Last Name

City

State

Phone

Medical Doctor

First Name

Last Name

City

State

Phone

Health History Questions

Have you been under a doctor's care during the past year?

Yes

If yes, please explain:

Have you ever been hospitalized?

Yes

If yes, please explain:

Have you ever had surgery?

Yes

If yes, please explain:

Have you ever had problems with local/intravenous/general anesthesia?

Yes

If yes, please explain:

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

Yes

If yes, please explain:

Do you have unhealed/recurrent injuries or inflamed areas, growths or sore spots in or around your mouth?

Yes

If so, please describe:

Do you have a prosthetic joint/implant?

Yes

If so, please describe where:

Do you have a heart valve replacement or vascular graft?

Yes

If yes, please explain:

Medications

Are you now taking:

Any kind of medication or pills?

Yes

OTC / "natural" blood thinners (Aspirin, Ginkgo Biloba, Vitamin E, Ginger, Turmeric)?

Yes

Rx blood thinners (Coumadin®, Pradaxa®, Eliquis®, Brilinta®, Xarelto®, Plavix®)?

Yes

Have you ever taken diet pills?

Yes

Any natural product, herbal supplement or homeopathic remedy?

Yes

Any bone density medications / bisphosphonates (Aredia, Zometa, Fosamax, Actonel, Reclast, Boniva, Prolia, etc.)?

Yes

If yes, for how long?

Are you taking tranquilizers, anti-depressants, sleeping pills, and/or anti-anxiety medications on a regular basis?

Yes

Please list all prescription and over-the-counter medications (including dosage) you are currently taking:

Allergies

Are you allergic to or have you had a reaction to:

Local anesthetic (numbing medicine)?

Yes

Penicillin?

Yes

Other antibiotics?

Yes

Sulfa drugs?

Yes

Sedatives or barbiturates?

Yes

Aspirin, ibuprofen, or NSAIDS?

Yes

Codeine or other pain killers?

Yes

Other medications?

Yes

Latex or rubber products?

Yes

Soy?

Yes

Eggs / yolk?

Yes

Sulfites?

Yes

Please list any drug or food allergies not listed above:

Women Only

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

Yes

If yes, expected delivery date?

Are you nursing?

Yes

Are you taking birth control pills?

Yes

If you are using oral contraceptives, it is important that you understand that antibiotics (and some other medications) may interfere with the effectiveness of oral contraceptives. Please consult with your physician.

Medical Conditions

Have you had or do you currently have:

Rheumatic fever or RHD?

Yes

Damaged heart valves or mitral valve prolapse?

Yes

Congenital heart disease?

Yes

Heart murmur?

Yes

High blood pressure?

Yes

Low blood pressure?

Yes

Chest pain / angina?

Yes

Heart attack(s)?

Yes

Coronary heart disease?

Yes

Irregular heart beat / palpitations?

Yes

Cardiac pacemaker?

Yes

Heart surgery?

Yes

Asthma?

Yes

Bronchitis or chronic cough?

Yes

Emphysema?

Yes

COPD?

Yes

Past history of pneumonia?

Yes

Difficulty breathing or other lung issues?

Yes

Sleep apnea?

Yes

Tuberculosis?

Yes

Hay fever or sinus problems?

Yes

Blood transfusion?

Yes

Blood disorder, such as anemia?

Yes

Bruise easily or bleeding tendency?

Yes

Hepatitis (A, B, C), jaundice, or liver disease?

Yes

Infectious mononucleosis?

Yes

Fainting spells?

Yes

Dizziness?

Yes

Do you smoke cigarettes?

Yes

Do you use chewing tobacco?

Yes

Do you smoke e-cigarettes or vape?

Yes

Do you use marijuana products?

Yes

A history of alcohol use?

Yes

A history of alcohol abuse?

Yes

A history of drug use?

Yes

A history of drug abuse?

Yes

Alcohol or drug rehabilitation?

Yes

Are you on a diet?

Yes

A denture or partial denture?

Yes

Pain and clicking of jaws?

Yes

Difficulty opening your mouth?

Yes

Seizures or epilepsy?

Yes

Stroke?

Yes

Other neurological disease?

Yes

Thyroid disease?

Yes

Diabetes?

Yes

Low blood sugar?

Yes

Kidney disease?

Yes

Are you on dialysis?

Yes

Swollen ankles, arthritis, or joint disease?

Yes

Gall bladder trouble?

Yes

Implant / artificial joints (heart valve, hip, knee, etc.)?

Yes

An organ transplant?

Yes

Immunosuppressed?

Yes

Osteoporosis / osteopenia?

Yes

Osteonecrosis?

Yes

Stomach ulcers, colitis, or GERD?

Yes

Contagious disease or STD?

Yes

AIDS or HIV?

Yes

HPV?

Yes

A tumor or growth?

Yes

Cancer / radiation / chemotherapy?

Yes

If yes, radiation to head or neck?

Yes

Do you wear contact lenses?

Yes

Eye disease or glaucoma?

Yes

Mental health problems / anxiety / depression?

Yes

Do you wish to speak with the doctor about anything privately?

Yes

Any other condition that is not listed above?

Yes

If so, please list:

Acknowledgment

I understand the importance of a truthful health history to assist the doctor in providing the best care possible. I have had the opportunity to discuss my health history with my doctor.

Signature of Patient/Guardian:

Date:

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue

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Acknowledgment of Receipt of Privacy Practices

Patient Information

First Name

Last Name

Date of Birth

Patient ID

Privacy Practices Acknowledgment

I have been given the opportunity to review the notice of Privacy Practices for Northern Star OMS. I understand the terms stated herein are to remain in effect throughout my treatment with Northern Star OMS.

Would you like a copy?

YES, I would like a copy

NO, I do not want a copy

YOU MAY REFUSE TO SIGN THIS ACKNOWLEDGMENT

Authorized Representatives

The following people are authorized to speak on behalf of my account and/or treatment plan:

Name

Relation to Patient

Phone #

Authorized for:

Account

Treatment Plan

Name

Relation to Patient

Phone #

Authorized for:

Account

Treatment Plan

Name

Relation to Patient

Phone #

Authorized for:

Account

Treatment Plan

Message Contact Preferences

Messages with confidential information may be left at:

Home Phone Number

Work Phone Number

Cell Phone Number

Email Address

Other Contact Method

Messages may be left at:

Home

Work

Cell Phone

Other

Appointment Confirmation Preferences

Please confirm my appointment by (Check all that apply):

Phone Call

Text Message

Signatures

Signature of Patient or Guardian:

Relation to Patient:

Date:

NSOMS Staff Signature:

Date:

Northern Star OMS reserves the right to modify the privacy practices as outlined in this notice.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue

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Financial Policy and Insurance Consent

We are happy to provide you with a pre-surgical estimate of fees for your treatment plan. As a surgical specialty office, Northern Star OMS (NSOMS) believes in delivering the finest care we are capable of at the most reasonable cost possible. In most cases, insurance does not cover the full cost of surgical care. Insurance coverage is designed to reduce your cost, not eliminate it.

It is your responsibility to know and understand your insurance policy and the coverage of benefits it provides. We will submit your insurance claim to your dental and medical insurance company(s) as a courtesy to you. This does not imply or guarantee that your particular plan will cover your anticipated procedure, either in part or in full. We require that you pay any deductibles, co-payments, and fees over your annual maximum at the time of surgery. If the processing of your claim has been delayed, we require your assistance in expediting the process.

After your claim has been processed by your insurance company(s), overpayments (if any) will be refunded to the appropriate party. This may be the insurance company, the patient, or the guarantor. If there is a balance, NSOMS will send you a statement. A 1.5% finance charge will be added to any balance over 30 days. In the event your account is placed with an agency for collection purposes, you will be responsible for all collection agency fees (up to 30% of the balance placed for collection). In addition, you will be responsible for all court costs, filing fees, and attorney fees should your account require litigation. Checks returned for insufficient funds will be assessed a $25.00 fee.

Estimated patient financial responsibility is due at the time of service.

Please initial on each line.

I acknowledge that it is my responsibility to know and understand my insurance policy(s) and the coverage of benefits it provides. I agree to be responsible for all charges for dental/medical services and materials not paid by my insurance plan(s), unless prohibited by law, or if the treating dentist or dental practice has a contractual agreement with my plan prohibiting all or a portion of such charges. I consent to allow NSOMS to use and disclose my protected health information to carry out payment activities in connection with my insurance claims.

I am aware that some professional services require the assistance of outside laboratories. Fees for providers of these services are not included in the surgical fee and are the responsibility of the patient. I understand I will be billed separately by the laboratory. Examples of services that would require the assistance of outside laboratories include, but are not limited to, CT scans and biopsy analysis.

I hereby authorize all practitioners of NSOMS to provide any insurance company(s), claim administrator(s), and consulting healthcare professional(s) information concerning health care, advice, treatment, or supplies utilized during my procedure. This information will be used exclusively for the purpose of evaluating and administering claims for benefits. I understand and accept that NSOMS submits claims electronically.

I understand the terms stated herein are to remain in effect throughout my treatment with NSOMS.

By signing this section, I authorize payment of insurance benefits directly to NSOMS.

Signature Section

Signature of Patient or Guardian

Relation to Patient

Date

NSOMS Staff Signature

Date

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue