New Patient Form

New Patient Registration Form

Thank you for choosing Casey Family Dentistry. Please help us meet your needs by filling out the form below. Thank you!

Patient Information​​​​​​​

Dental Insurance

Primary Carrier
Secondary Carrier

Account Information - Person Financially Responsible for Account

Getting to Know You

Is another member of your family or relative a patient at our office? If so, please indicate their name and your relationship to them.
Your Emergency Contact - Please indicate the name, phone number, and your relationship
Closest Relative not living with you - Please indicate the name, phone number, and your relationship

Consent for Treatment

1. I hereby authorize doctor or designated staff to take x-rays, study models, photographs, and any other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of my dental needs.
2. Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care
3. I agree to the use of anesthetics, sedatives and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.
4. Last, I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that payment is due at the time of service unless other arrangements have been made. In th event payments are not received by agreed upon dates, I understand that a 1-1/2% late charge (1.8% APR) may be added to my account.

Medical History

  • Heart (Surgery, Disease, Attack)

  • Chest Pain

  • Congenital Heart Disease

  • Heart Murmur

  • High Blood Pressure

  • Mitral Valve Prolapse

  • Artifical Heart Valve

  • Heart Pacemaker

  • Rheumatic Feaver

  • Arthritis/Rheumatism

  • Cortisone Medicine

  • Swollen Ankles

  • Stroke

  • Diet (Special/Restricted)

  • Artificial Joints (hip, knee, etc.)

  • Kidney Trouble

  • Ulcers

  • Diabetes

  • Thyroid Problems

  • Glaucoma

  • Contact Lenses

  • Emphysema

  • Chronic CoughTuberculosis

  • Asthma

  • Hay Fever

  • Latex Sensitivity

  • Allergies or Hives

  • Sinus Trouble

  • Radiation Therapy

  • Chemotherapy

  • Tumors

  • Hepatitis A (infections) B (serum)

  • Venereal Disease

  • A.I.D.S.

  • H.I.V. Positive

  • Cold Sores/Fever Blisters

  • Blood Transfusion

  • Hemophilia

  • Sickle Cell Disease

  • Bruise Easily

  • Liver Disease

  • Yellow Jaundice

  • Neurological Disorders

  • Epilepsy or Seizures

  • Fainting or Dizzy Spells

  • Nervous/Anxious

  • Psychiatric/Psychological Care

Are you Pregnant?
Are you Nursing?
Taking birth control pills?

I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of any change in my health or medication

Dental History

Hot or cold?
Sweets?
Biting or Chewing?
Have you noticed any mouth odors or bad tastes?
Do you frequently get cold sores, blisters or any other oral lesions?
Clench or grind your teeth while awake or sleep?
Bite your lips or cheeks regularly?
Hold foreign objects with your teeth?
Mouth breath while awake or asleep?
Have tired jaws, specially in the morning?
Smoke/Chew tobacco?
Orthodontic treatment?
Oral Surgery?
Periodontal Treatment?
Your teeth ground or the bite adjusted?
A bite plate or mouth guard?
A serious injury to the mouth or head?
Clicking or popping jaw?
Pain? (joint, ear, side of face)
Difficulty in opening or closing the mouth?
Sore muscles(neck, shoulder)?
Headaches, neckaches or shoulder aches?
Would you like to keep all of your teeth all of your life?
Do you feel nervous about having dental treatment
Have you ever had an upsetting dental experience?

FINANCIAL POLICY

Click here to read the Financial Policy. By checking the box below, you agree to the statements noted on the policy

AUTHORIZATION FOR SUBMISSION OF CLAIMS AND ASSIGNMENT OF BENEFITS

I authorize the health care provider named above to submit claims for payment for services to the healthcare service plans or insurance companies named below, on my behalf and in my name, and assign to such provider the group insurance benefits otherwise payable to me, but not to exceed the provider's actual charges for the covered services. I understand that I am financially responsible for any charges not covered by the group insurance benefits.

NOTICE OF PRIVACY PRACTICES

Click here to read the Notice of Privacy Practices. By checking the box below, you acknowledge the receipt of Notice of Privacy Practices.

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION

I authorize the physician, dentist or other health care provider named above to release to hospital or health care service plans, insurance companies, self-insurers, or their representatives, any and all information and records (including x-rays) about my medical history, or about services rendered or treatment given to me, that is needed to review, investigate or evaluate any claim for benefits.

If my coverage is under a group master agreement held by my employer, an association, trust fund, union or similar entity, this authorization also permits disclosure to them for purposes of utilization review or financial audit. This authorization shall remain effective for up to five years from this Date.

I know that I have the right to receive a copy of this authorization if requested.

HIPAA ​​​​​​​

Sign Off on HIPAA

Health Insurance Portability and Accountability Act, HIPAA provides national standards to protect the privacy of personal health information. To improve the efficiency and effectiveness of the health care system, the Health Insurance Portability and Accountability Act (HIPAA) of 1996, Public Law 104-191, included "Administrative Simplification" provisions that required HHS to adopt national standards for electronic health care transactions. Congress incorporated into HIPAA provisions that mandated the adoption of Federal privacy protections for individually identifiable health information.

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