• Home
  • Services
    • Latest Technology
    • Exam and Prevention
    • Crowns and Bridges
    • Cosmetic Dentistry
    • Bruxism – Teeth Grinding
    • Dentures
    • Implants
    • Invisalign
    • Snoring and Sleep Apnea
    • Botox
    • TMJ and Occlusion
    • Financing – Care Credit
    • DEEGAN DENTAL SAVINGS CLUB
  • Meet the Staff
  • Reviews
    • Read our 5 Star Reviews
  • Specials
  • Contact Us
  • Patient Resources
    • Registration and Treatment Form
    • Patient Advisory and Acknowledgment COVID-19
  • Deegan Dental News
    • Deegan Dental Monthly Newsletter

Deegan Dental - For a Lifetime of Healthy Smiles

Effie Deegan, D.M.D. | 23 Old Short Hills Rd West Orange, New Jersey, 07052 | 973-736-4432 | 973-323-2092 frontdesk@deegandental.com | Contact Us

Registration and Treatment Form

October 14, 2020 By Deegan Dental

Date: ______________________Home: ____________________Cell: ______________________

PATIENT INFORMATION

Name: Last______________________ First_____________________________ Middle Initial____

SS/HIC/Patient ID# _________________________________

Address/City/State/Zip code: ________________________________________________________________________________

Email: _______________________________________________________

Sex: M/F______               Age: ______       Birthdate: _______________

Married/Single/Widowed/Divorced/Minor/Separated/Partnered ___________________

Patient Employer/School:_____________________________Ocuupation:_________________________

Employer/School Address: _____________________________________________________________________________________

Employer/School Phone Number: _____________________________

Whom May we thank for referring you? ____________________________________________________

In case of an emergency who may, we notify?

Name/Phone Number: _________________________ ________________________________________

PRIMARY INSURANCE

Person Responsible for your Account/Name: ________________________________________________

Relation to Patient: _______________Subscriber DOB:______________ Subscriber ID#/SS# ____________________

Address If different from Patient:_________________________________________________________Phone#______________________

Person Responsible Employed by:__________________________________________Occupation:_________________

Business Address:_______________________________________________Business#___________________________

Insurance Company:_________________________________ Insurance#________________________________

Insurance Address:_________________________________________________________________________

Group#_______________________ Subscriber#_______________________________

ADDITIONAL INSURANCE

Is patient covered by additional insurance? Yes/NO__________

Subscriber Name:_______________________ Subscriber DOB:___________ Subscriber ID#/SS# ____________________

Address If different from Patient:_________________________________________________________Phone#______________________

Person Responsible Employed by:__________________________________________Occupation:_________________

Business Address:_______________________________________________Business#___________________________

Insurance Company:_________________________________ Insurance#________________________________

Insurance Address:______________________________________________________________________

Group#_______________________ Subscriber#_______________________________

 DENTAL HISTORY

Reason for Today’s Visit ___________________________________________________________

Date of Last dental visit ________________

Former Dentist_____________________________ Date of last dental

X-rays____________________

Address____________________________________________________________________________

Check if you have had problems with the following:

___ Bad breath

___ Bleeding gum

___ Clicking or popping jaw

___ Food collection between teeth

___ Grinding Teeth

___ Loose teeth or broken fillings

___ Periodontal Treatment

___ Sensitivity to cold

___ Sensitivity to hot

___ Sensitivity to sweets

___ Sensitivity when biting

___ Sores or growths in the mouth

MEDICAL HISTORY

Physician Name:_______________________________ Date of Last Visit:_________________________

Have you had any serious illness or operations? Yes/No If yes, describe? ___________________________________

Have you ever had a blood transfusion? __Y__N If yes, give approximate date_________________________

Have you ever taken any of the group of drugs collectively referred to as “fen-phen”? These include combinations of Lonimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine). __Yes/__No

Are you pregnant? ________________________ Nursing?________________ Taking Birth Control Pill?____________

Check if you have or have had any of the following:

___Anemia

__Arthritis, Rheumatism

___Artificial Heart Valves

___Asthma

___Back Problems

___Blood Diseases

___Cancer

___Chemical Dependency

___Chemotherapy

___Circulatory Problems

___Cortisone Treatments

___Cough, Persistent

___Diabetes

___Epilepsy

___Fainting

___Glaucoma

___Headaches

___Heart Murmur

___Heart Problems

___Hemophilia

___Hepatitis

___High Blood Pressure

___HIV/AIDS

___Jaw Pain

___Kidney Disease

___Liver Disease

___Mitral Valve Prolapse

___Pacemaker

___Radiation Treatment

___Respiratory Disease

___Rheumatic Fever

___Scarlet Fever

___Shortness of Breath

___Skin Rash

___Stroke

___Swelling of Feet or Ankles

___Thyroid Problems

___Tobacco Habit

___Tonsilitis

___Tuberculosis

___Ulcer

___Venereal Disease

 

AUTHORIZATION

I certify that I, and/or my dependent(s), have insurance coverage with ____________________________(Name of Insurance) and assign directly to Dr. _________________________________ all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named dentist may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

Signature of Ptient,Parent,Guardian or Personal Representative:___________________________________________

Print Name:_________________________________________               Date:_________________________

Relationship to Patient: _____________________________

Payment is due in full at the time of treatment unless prior arrangements have been approved.

GENERAL DENTISTRY INFORMED CONSENT

Patient: _________________________________________________________________

Drugs and Medication: I understand that antibiotics and/or other medications prescribed to me may cause allergic reactions causing redness and swelling of tissue, pain, itching, vomiting, and or/ anaphylactic shock. For this reason, I have provided the doctor/ staff with all my medical history to the beast of my knowledge.

Changes in Treatment Plan: I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during the initial examination. For example, Root Canal therapy following routine restorative procedures. I give my permission to my dentist to make any/all changes and additions, as necessary.

I understand that dentistry is not an exact science and that therefore, reputable practitioners cannot properly guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the dental treatments which have requested and authorized.

I hereby authorize any of the doctors or dental auxiliaries to proceed with and perform the dental restorations and treatments as explained to me. I understand that this is only an estimate and subject to modification depending on unforeseen or undiagnosable circumstances that may arise during the course of treatment. I understand that regardless of any dental insurance coverage I may have, I am responsible for the payment of dental fees. I agree to pay any attorney fees or court costs, that may be incurred to satisfy the obligation.

Signature of Patient:__________________________________ Date:__________________________

Signature of Doctor:__________________________________ Date:______________________

ACKNOWLEDGMENT OF RECEIPT OF HIPAA NOTICE OF PRIVACY PRACTICES

(“Acknowledgment”)

I acknowledge that I have received a copy of this Dental Practice’s HIPAA Notice of Privacy Practices.

Patient Name: _____________________________________________

Patient Signature:__________________________________________ Date:__________________________

OR

Signature of Personal Representative: ____________________________________

Authority of Personal Representative to Sign for Patient (check one)

___ Parent ___ Guardian ___Power of Attorney __Other

Please Note: It is your right to refuse to sign this Acknowledgment.

Dental Office Use Only

I tried to obtain written Acknowledgment by the individual noted above of recipient of our Notice of Privacy Practices, but it could not be obtained because:

____ An emergency prevented us from obtaining acknowledgment.

____ A communication barrier prevented us from obtaining acknowledgment.

____ The individual was unwilling to sign.

____ Other:_____________________________________________________________________________

Staff Member Signature:________________________________________ Date:______________________

 

 

Filed Under: Patient Resources

Follow Us!

Visit Us On FacebookVisit Us On LinkedinVisit Us On Instagram

Deegan Dental

  • Office (973) 736 - 4432
  • Fax (973) 243 - 0968
  • frontdesk@deegandental.com
  • 23 Old Short Hills Rd
    West Orange, New Jersey, 07052
  • Latest Technology
  • Exam and Prevention
  • Crowns and Bridges
  • Cosmetic Dentistry
  • Dentures
  • Implants
  • Bruxism – Teeth Grinding
  • Invisalign
  • Snoring and Sleep Apnea
  • Botox
  • TMJ and Occlusion
  • Financing – Care Credit
  • DEEGAN DENTAL SAVINGS CLUB

Copyright © 2021 · Designed by Tektherapy · WordPress · Log in

Deegan Dental | Specialty #3749 | Fellow of the American College of Prosthodontics