Old PATIENT REGISTRATION

DATE 7/12/2011
PATIENT REGISTRATION
ID
Chart ID
Name

First NameMiddle InitialLast Name
Patient Is

Policy HolderResponsible Party
Responsible Party (if someone other than the patient)
Name

First NameMiddle InitialLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pager
Birth Date

MonthDayYear
Date
Home Phone
Work Phone
Ext
Cellular
Soc Sec
Drivers Lic
Responsible Party is also a Policy Holder for PatientPrimary Insurance Policy HolderSecondary Insurance Policy Holder
Patient Information
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pager
Home Phone
Work Phone
Cellular
Ext
Birth Date

MonthDayYear
Date
Age
Marital Status

MaleFemaleMarriedSingleDivorcedSeparatedWidowed
Soc. Sec
Drivers Lic
E mail
example@example.com
I would like to receive correspondences via e-mail.
Employment Status

Full TimePart TimeRetired
Student Status

Full TimePart Time
Medicaid ID
Employer ID
Carrier ID
Pref. Dentist
Pref. Hyg.
Pref. Pharmacy.
Additional Comments
Primary Insurance Information
Name of Insured
Relationship to Insured:

SelfSpouseChildOther
Insured Soc. Sec
Insured Birth Date

MonthDayYear
Date
Employer
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Rem. Benefits
Rem. Deduct
Ins. Company
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Insurance Information
Name of Insured
Relationship to Insured:

SelfSpouseChildOther
Insured Soc. Sec
Insured Birth Date

MonthDayYear
Date
Employer
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Rem. Benefits
Rem. Deduct
Ins. Company
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MEDICAL HISTORY
PATIENT NAME
Birth Date

MonthDayYear
Date
Although dental personnel primarily treat the area in and around your mouth, your mouth is a 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?

YesNo
If yes, please explain
Have you ever been hospitalized or had a major operation?

YesNo
If yes, please explain
Have you ever had a serious head or neck injury?

YesNo
If yes, please explain
Are you taking any medications, pills, or drugs?

YesNo
If yes, please explain
Do you take, or have you taken, Phen-Fen or Redux?

YesNo
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?

YesNo
Are you on a special diet?

YesNo
Do you use tobacco?

YesNo
Women:
Are you Pregnant/Trying to get pregnant?

YesNo
Taking oral contraceptives?

YesNo
Nursing?

YesNo
Are you allergic to any of the following?
AspirinPenicillinCodeineAcrylicLocal AnestheticsMetalSulfa drugsLatexOther
If yes, please explain
Do you have, or have you had, any of the following?
ADS/HV PositiveAlzheimer's DiseaseAnaphylaxisAnemiaAnginaArthritis/GoutArtificial Heart ValveArtificial JointAsthmaBlood DiseaseBlood TransfusionBreathing ProblemBruise EasilyCancerChemotherapyChest PainsCold Sores/Fever BlistersCongenital Heart DisorderConvulsions
Cortisone MedicineDiabetesDrug AddictionEasily WindedEmphysemaEpilepsy or SeizuresExcessive BleedingExcessive ThirstFrequent CoughFrequent DiarrheaFrequent HeadachesGenital HerpesGlaucomaHay FeverHeart Attack/FailureHeart MurmurHeart PacemakerHeart Trouble/Disease
HemophiliaHepatitis AHepatitis B or CHerpesHigh Blood PressureHigh CholesterolHives or RashHypoglycemiaIrregular HeartbeatKidney ProblemsLeukemiaLiver DiseaseLow Blood PressureLung DiseaseMitral Valve ProlapseOsteoporosisPain in Jaw JointsParathyroid DiseasePsychiatric Care
Radiation TreatmentsRecent Weight LossRenal DialysisRheumatic FeverRheumatismScarlet FeverShinglesSickle Cell DiseaseSinus TroubleSpina BifidaStomach/Intestinal DiseaseStrokeSwelling of LimbsThyroid DiseaseTonsillitisTuberculosisTumors or GrowthsUlcersVenereal DiseaseYellow Jaundice
Have you ever had any serious illness not listed above?

YesNo
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.
SIGNATURE OF PATIENT, PARENT, or GUARDIAN

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DATE

MonthDayYear
Date
DR. JORDAN J. TILDEN D.D.S., P.C.

OFFICE & FINANCIAL POLICY
Thank you for choosing our office for your dental care. It is our mission to provide you with the highest quality of patient care. Please review our financial policy and sign below.

Please notify us of any change or problem in your or your child's health immediately.

Our office requires that the patient portion of payment is due at the time of service.

We calculate your portion based on the most up-to-date information we have by verifying your benefits with your insurance provider, but it is only an estimate. Any amount not paid by insurance is the patient's responsibility. We encourage you to discuss any concerns or questions you may have regarding your specific plan with your insurance company.

We accept all major credit cards, personal checks, and cash. To make your dental care affordable, we also offer no-interest payment plans through CareCredit.

We will do our best to contact you prior to your appointment, however, this is a courtesy reminder and you are still responsible for keeping your appointment. A fee of $50 is charged for appointments that are missed or cancelled without 48 hour notice.

We send out regular statements for any balance that may accrue on your account. An interest charge of 5% monthly will be applied to any account with a balance showing no payment activity after 90 days of issuance of the first statement. Though we try to resolve all financial issues as cordially as possible, continued lack of payment will result in the account being sent to a collection agency for resolution. Please speak with our staff for an explanation of financial options available.
I understand and agree to the office policy of Jordan J. Tilden D.D.S., P.C.
Patient or Guardian Signature

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Printed Name of Signer

First NameLast Name
Dated

MonthDayYear
Date
Dr. Jordan J. Tilden D.D.S., P.C.
We would like to thank you for choosing Jordan J. Tilden D.D.S., P.C. as your dental provider. To keep you informed of our current office and financial policies we ask that you read and initial the following areas prior to any treatment.

Credit Card Policy: Our office requires a valid credit card or direct bank debit account information prior to services being rendered. Your credit card/bank account will not be charged until 90 days after the services provided have been processed by your dental insurance carrier and the balance deemed your responsibility. You will be notified by letter and/or phone of any outstanding balances prior to our office charging your card or account at which time we will inform you of all of your payment options.
Name of Card Holder
Name of Patient
Card #
Exp
VisaMaster CardDiscoverAmerican Express
Authorized Signature

Clear
Cancelled/Failed Appointments: If you are unable to keep your scheduled appointment, please call our office within 48 hours to re-schedule your appointment. This will enable us time to use your appointment time for another patient.

No Insurance Coverage: Payment will be due at the time of service. If you are unable to pay your balance in full, you will need to make a prior arrangement with our Business Manager or Financial Coordinator.

If You Have Insurance Coverage: Please bring your insurance card with you at the time of your appointment. For insurance plans that we contact with, your carrier requires that all co-pays be paid prior to any services being rendered. The co-pay requirement cannot be waived by our practice, as it is a requirement placed on you by your insurance carrier.

HMO or DMO Insurance Plans: For HMO and DMO insurance plans that we participate in, your insurance carrier requires you to obtain a referral from your primary care physician and/or other medical professional before receiving services. Please bring that referral slip with you. Any services received without a referral or proper authorization will be your responsibility.

Returned Checks: A $30 charge will be added to your account for any check returned by your bank for any reason.

Requesting Dental Records & X-rays: We will provide you a copy of your dental records upon request. You will need to sign a letter of release at the time of pick-up. Please allow 24 hours for us to copy your x-rays. If you wish for x-rays to be mailed, letter of release must be signed prior to mailing. Please allow 2-4 business days for records to arrive. We are also able to email x-rays if needed.
ASSIGNMENT & INSTRUCTION FOR DIRECT PAYMENT TO DOCTOR

PRIVATE & GROUP ACCIDENT, DENTAL & HEALTH INSURANCE
Patient/Policy Holder
Employer of Policy Holder
Group #
Identification # /Social Security #
I hereby instruct and direct that Insurance Company to pay by check made out to Jordan J. Tilden D.D.S., P.C. 331 EastOntario. St., Chicago, IL. 60611
If my current policy prohibits direct payment to my dentist, then I hereby also instruct and direct you to make out the check to me, (the patient or policy holder) and mail it as follows:

Jordan J. Tilden D.D.S., P.C. 331 East Ontario St.

The professional or medical/dental expense benefits allowable and otherwise payable to me under my current insurance policy as payment toward the total charges for the professional services rendered. This is a direct assignment of my rights and benefits under this policy. This payment will not exceed my indebtedness to the above- mentioned assignee, and I have agreed to pay, in a current manner, any balance of said professional service charges over and above this insurance payment.
A photocopy of this assignment shall be considered as effective and valid as the original.

I also authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in this case.
Dated

MonthDayYear
Date
Signature of Policy Holder/Claimant if other than Policy Holder

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ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES NOTICE
I First Name , have received a copy of Jordan J. Tilden D.D.S., P.C. Notice of Privacy Practices.
Signature

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Printed Name
Date

MonthDayYear
Date
Should be Empty:

DATE 7/12/2011

PATIENT REGISTRATION

Responsible Party (if someone other than the patient)

Patient Information

Primary Insurance Information

Secondary Insurance Information

MEDICAL HISTORY

Women:

Are you allergic to any of the following?

Do you have, or have you had, any of the following?

DR. JORDAN J. TILDEN D.D.S., P.C.

Dr. Jordan J. Tilden D.D.S., P.C.

ASSIGNMENT & INSTRUCTION FOR DIRECT PAYMENT TO DOCTOR

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES NOTICE