Step 1 of 7 14% Patient RegistrationFirst Name:* Last Name:* Middle Initial: Patient Is: Policy Holder Responsible Party Address Address: Address 2: City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State: ZIP Code: Home Phone:Work Phone:Ext: Cellular:Email Address: I would like to receive correspondence via email. I would like to receive correspondence via email. Birth Date: MM slash DD slash YYYY Responsible Party is also a Policy Holder for Patient Primary Insurance Policy Holder Secondary Insurance Policy Holder Sex: Male Female Marital Status: Married Single Divorced Separated Widowed Section 2Employment Status: Full Time Part Time Retired Student Status: Full Time Part Time Retired Pref. Pharmacy: Section 3Referred By Previous Dentist Emergency Contact Emergency Contact #Primary Insurance InformationName of Insured: Relationship to Insured: Self Spouse Child Other Insured Soc. Sec: Insured Birth Date: MM slash DD slash YYYY Employer: Ins. Company: Secondary Insurance InformationName of Insured: Relationship to Insured: Self Spouse Child Other Insured Soc. Sec: Insured Birth Date: MM slash DD slash YYYY Employer: Ins. Company: Self or Bed Partner QuizDo you or your partner?Stop breathing while sleeping Yes No Gasp while sleeping Yes No Tend to fall asleep during the day Yes No Snore loudly and disruptively while sleeping Yes No Grind or clench their teeth while sleeping Yes No Toss and turn while sleeping Yes No If you answered yes to any of these questions, you or your bed partner would benefit from a screening for sleep apnea! Patient Medical HistoryPatient Name:* Birth Date:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date Created:* MM slash DD slash YYYY Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your en ore 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.When was your last Dental visit? Comment:Are you taking any medications, pills, or drugs? Yes No Have you ever taken Fosamaxr, Boniva, Actonel or any other medications containing bisphosphonales? Yes No Do you use tobacco? Yes No Are you allergic to any of the following? Aspirin Penicillin Codeine Acrylic Metal Latex Sulfa Drugs Local Anesthetics Women: Are you... Pregnant? Trying to get pregnant? Taking oral contraceptives? Nursing? Sleep ApneaDo you snore? Yes No Have you ever been diagnosed with Sleep Apnea? Yes No Do you have, or have you had, any of the following?AIDS/HIV Positive Yes No Anaphylaxis Yes No Anemia Yes No Arthritis/Gout Yes No Artificial HeartValve Yes No Artificial Joint Yes No Asthma Yes No Blood Disease Yes No Blood Transfusion Yes No Breathing Problems Yes No Cancer Yes No Chemotherapy Yes No Chest Pains Yes No Cold Sores/Fever Blisters Yes No Congenital Heart Disorder Yes No ConvuIsions Yes No Diabetes Yes No Drug Addiction Yes No Emphysema Yes No Epilepsy or Seizures Yes No Excessive Bleeding Yes No Excessive Thirst Yes No Fainting Spells/Dizziness Yes No Frequent Headaches Yes No Glaucoma Yes No Heart Attack/Failure Yes No Heart Pacemaker Yes No Heart Trouble/Disease Yes No Hemophilia Yes No Hepatitis A Yes No Hepatitis B or C Yes No High Blood Pressure Yes No High Cholesterol Yes No Kidney Problems Yes No Leukemia Yes No Liver Disease Yes No Lung Disease Yes No MitraI Valve Prolapse Yes No Osteoporosis Yes No Pain in Jaw Joints Yes No Parathyroid Disease Yes No Radiation Treatments Yes No Rheumatism Yes No Sickle Cell Disease Yes No Sinus Trouble Yes No Stomach/Intestinal Disease Yes No Stroke Yes No Thyroid Disease Yes No Tonsillitis Yes No Tuberculosis Yes No Tumors or Growths Yes No Have you ever had any serious illness not listed above? Yes No Is there any additional information not covered above we need to be aware of? 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 patent's) health. responsibility to inform the dental office of any changes in medical status.Signature of Patient, Parent or Guardian: *A new policy has been in effect as of 2014. All patients must give 48 hours' notice of cancellation for an appointment. If the 48-hour notice was not met or a patient fails his or her appointment there will be a $75.00 charge for Hygiene Appointment and $150.00 for a Restorative Appointment to his or her account.HIPPA Patient Consent Form Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office. You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement. By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment, and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The patient understands that: Protected health information may be disclosed or used for treatment, payment, or dental/health care operations. The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice. The Practice reserves the right to change the Notice of Privacy Practices. The patient has the right to restrict the use of their information but the Practice does not have to agree to the restrictions. The patient may revoke this Consent in writing at any time and all future disclosures will then cease. The Practice may condition receipt of treatment upon the execution of this Consent. Signature:Date: MM slash DD slash YYYY Financial PolicyThank you for choosing Brighter Smile for your health care needs. We are committed to providing the very best dental care treatment. We realize that every person’s financial situation is different. For this reason, we have worked hard to provide a variety of payment options to help you receive the dental care you need and deserve that allows you to enjoy a healthy, beautiful smile with respect to your budget. The following is a statement of our financial Policy, which you must read, agree to, and sign prior to treatment. Our Financial Policy applies to all services rendered by our office staff. Dental treatment is an excellent investment in an individual’s medical and psychological care. We are always available to answer your questions or assist you in any way we can. Practice payment policy: Patients/guardians are financially responsible for all charges, regardless of third party. Full payment is due at the time of services, unless prior insurance billing arrangements have been made. Patients with insurance will be required to pay all “out-of-pocket” fees at the time of service We accept : Cash, Check, and all Major credit cards. Patient / Guardian Financial Responsibilities: Provide accurate information: You have a responsibility to provide accurate and complete information about your mailing address, Dental insurance and other billing information. If any information changes- names, address, phone, insurance coverage, etc – you must inform this practice immediately. Insurance denials or billing errors due to patient supplied information will result in the transfer of the account balance to the patients’ immediate financial responsibility. Self-Pay Patients Patients without insurance coverage are expected to pay for the services received in full at the time of service, unless a satisfactory payment agreement has been arranged with our billing manager prior to the services being rendered. Patient with Private Insurance Our Dentists participate with most major insurance companies. We will file claims to your insurance company for payment directly to our practice. For participating insurance plans, the practice will accept payment based on contractual agreements. For plans in which we do not participate(i.e. there is no contractual agreement) the practice will expect full payment from the patient at the time of service. Any coverage or payment dispute is a matter between the insurance policy holder and the insurance company. Patient Payment Agreement – I understand that I am financially responsible for all charges regardless of the third-party involvement. I agree to pay any deductibles, co-payment, or service deemed as “non-covered” by my insurance carrier at the time of service. If any portion of the balance due, insurance does not pay on my account in 60 days, the outstanding services will become my responsibility, and charged to the card on file. Optional Payment Terms: Full Pay Cash Discount: We offer a 10% accounting courtesy for all treatment that is paid in full (cash or check) at the time of proposal. We will still file your insurance and payment will go directly to you the patient. Full Pay DOS Cash Discount:We offer a 5% accounting courtesy when your treatment plan co-pay is paid in full (cash or check) at the time of proposal. Major Service - Two Payment Option:We offer a two-payment option for Crown, Bridge, and Denture treatment. We ask that you pay one-half of your co-payment at the appointment and the second half 1 month later with credit card on file for auto payment. Full Pay DOS Cash Discount:We offer a 5% accounting courtesy when your treatment plan co-pay is paid in full (cash or check) at the time of proposal. Term Loan:By arrangement with Care Credit, Lending Club, and Alphaeon we offer our patients, upon approval, an interest-free term loan (3, 6, 12, or 24 months) with no down payment, no annual fee, and no prepayment penalty. Please ask for an application. Broken appointments: A specific amount of time is reserved especially for you and we strongly encourage all patients to keep their appointments. If you must change your appointment, we require at least a two business days (48-hour) notice to avoid a $75-$150 cancellation fee. Signature:*Patient/Guardian SignatureDate:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Text Consent FormDue to the changing world of healthcare and technology, Brighter Smile has the ability to provide our patients with certain types of information via-email and/or text messaging. If you wish to have the opportunity to receive information of this type, please complete the form below. Brighter Smile believes strongly in protecting the privacy of our patients. When you provide the information to us, it is only used as a way to communicate with you. In order to protect your privacy, no confidential or personal information will be sent from Brighter Smile via email or text messaging. Brighter Smile does not share the names, e-mail and or telephone numbers of patients with any other company, or with any other patient. IFull Name consent to communicate via email and/or textPatient Signature*Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 4845 N. Milwaukee Ave. Chicago, IL 60630 773-647-1093 www.brightersmilechicago.comCancellation Policy: Once a dental appointment has been made, please keep in mind that this time has been reserved especially for you. We require a full 24-hour notice (business hours) for any appointment changes or cancellations-including failed appointments. We reserve the right to charge $75.00 for hygiene-related appointments and $150.00 for restorative related appointments without 24 “business” hours including failed appointments.Brighter Smile requires a credit card on file to secure your reserved dental appointment.* Visa Master Card Amex Discover Other Please Specify:* Card Number:* Expiration Date:* CVV:* (3 digit verification #) / (Amex 4 digit # front)*Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until cancelled.By signing this notice of cancellation policy, I am acknowledging that the policy has been read in its entirety. I also understand that payment of this account is my full responsibility.Signature:Patient / Parent / Guardian SignatureDate: MM slash DD slash YYYY
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