New Adult Patient Registration Form

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PATIENT INFORMATION

Full Name

Phone Number

Home Phone

Date of Birth

Address

City

Postal Code

INSURANCE INFORMATION

Primary Insured

Date of Birth

Employer

Insurance Company

Group / Policy Number

ID / Certificate Number

If covered under spouse’s plan as secondary coverage

Secondary Insured

Date of Birth

Employer

Insurance Company

Group / Policy Number

ID / Certificate Number

MEDICAL HISTORY

Name of Physician

Address of Physician

Office Phone Number

Have you had an allergic or unusual reaction to any of the following? (Please check mark the boxes below)

Aspirin

Yes No

Codeine

Yes No

Dental Anesthetic

Yes No

Penicillin

Yes No

Other

Please answer all questions below:

Does he/she take any medications? If so, what are they?

Does he/she have any heart problems? If so, what kind?

Does he/she have any congenital or developmental disorders/disabilities?

Has he/she ever had any major operations? If so, what kind?

Has he/she ever been involved in a serious accident?

Has he/she recently had a communicable disease?

DENTAL HISTORY

Previous Dentist

Date of Last Visit

In past years have they been to a dentist on a regular basis? How often?

Is he/she presently in any dental pain?

Does he/she engage in any oral habits?

Please list some typical snacks he/she consumes on a regular basis.

Does he/she consume juice on a regular basis?

What is your major dental concern for your child at this time?

Office Policy

Payment is required after EACH appointment for work done that day.
We will gladly complete Dental Insurance Claim Forms with the following understanding:
a) The parent/guardian is financially responsible for the entire cost of the treatment.
b) Payment is to be made to “Samad Dental Studio” by the patient/guardian or by direct billing to the insurance company.

iTrans

Benefits payable from claims submitted electronically will be assigned to Samad Dental Studio and payment will be received by the Dentist directly.

CANCELLATION/ NO SHOW POLICY

At least 24 hours notice is required if you must cancel/reschedule your appointment for any reason.
Missed Appointments will incur a firm charge of $50.00
All outstanding fees must be paid in full before further appointments will be booked.
Should you miss an appointment, it is your responsibility to call and rebook.
Frequent or numerous cancellations and/or no shows will result in permanent discharge from the practice.

Statement of Understanding

I hereby acknowledge and confirm that I have read the policy stated above. I agree to conduct my activities in accordance with Samad Dental Studio's policy and understand that breaching it in anyway may result in disciplinary action.

Name of Patient

Date of Signed

Message

By checking this checkbox, I hereby understand and agree to the conditions mentioned above.