Patient Sign-in

Patient Registration Form

Patient Sign-in
New patient Registration
Medical History
Medical history
Dental History
Dental history

Patient Registration( * mandatory to fill )

How do we contact you?( * mandatory to fill )

IN CASE OF EMERGENCY, CONTACT (Specify someone who does not live in your household.)

SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

Please select below

Are You Married?
Yes No
Do You Have Dental Insurance?
Yes No
Do You Have Additional Insurance?
Yes No
I have read the above choices

Spouse Information( * mandatory to fill )

Dental Insurance Information( * mandatory to fill )

SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

Additional Insurance Information( * mandatory to fill )

ASSIGNMENT AND RELEASE

I certify that I, and/or my dependent(s), have insurance coverage with

and assign directly to

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
 
(Please click below to draw/upload sign)
(Your IP Address : )

Medical History

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.

(All questions are required * )

Have you ever used a bisphosphonate medication? Common brand names are Fosamax, Actonel, Atelvia, Didronel, Boniva
Yes
No
Have you ever taken any of the group of drugs collectively referred to as "fen-phen"? These include combinations of Ionimin, Adipex, Fastin(brand names of phentermine), Pondimin (fenfluramine) and Redux(dexfenfluramine).
Yes
No
I have answered all the above questions

Medical History

Are you a woman?
Yes
No
Are you allergic to any of the following?
Has there been any change in your health since your last dental appointment?
Yes
No
I have answered all the above questions

Medical History

Place a mark on 'Yes' or 'No' to indicate if you had any of the following

AIDS/HIV Positive
Yes
No
Anemia
Yes
No
Arthritis, Rheumatism
Yes
No
Artificial Heart Valves
Yes
No
Artificial Joints
Yes
No
Asthma
Yes
No
Back Problems
Yes
No
Bleeding abnormally, with extractions or surgery
Yes
No
Blood Disease
Yes
No
Cancer
Yes
No
Chemical Dependency
Yes
No
Chemotherapy
Yes
No
Circulatory Problems
Yes
No
Congenital Heart Lesions
Yes
No
Cortisone Treatments
Yes
No
Cough, persistent or bloody
Yes
No
Diabetes
Yes
No
Emphysema
Yes
No
Epilepsy
Yes
No
Fainting or Dizziness
Yes
No
Glaucoma
Yes
No
Headaches
Yes
No
Heart Murmur
Yes
No
Heart Problems
Yes
No
Hepatitis
Yes
No
Herpes
Yes
No
High Blood Pressure
Yes
No
Jaundice
Yes
No
Jaw Pain
Yes
No
Kidney Disease
Yes
No
Liver Disease
Yes
No
Low Blood Pressure
Yes
No
Mitral Valve Prolapse
Yes
No
Nervous Problems
Yes
No
Pacemaker
Yes
No
Psychiatric Care
Yes
No
Radiation Treatment
Yes
No
Respiratory Disease
Yes
No
Rheumatic Fever
Yes
No
Scarlet Fever
Yes
No
Shortness of Breath
Yes
No
Sinus Trouble
Yes
No
Skin Rash
Yes
No
Special Diet
Yes
No
Stroke
Yes
No
Swollen Feet or Ankles
Yes
No
Swollen Neck Glands
Yes
No
Thyroid Problems
Yes
No
Tonsillitis
Yes
No
Tuberculosis
Yes
No
Tumors or Growths on head or neck
Yes
No
Ulcer
Yes
No
Venereal Disease
Yes
No
Weight Loss, unexplained
Yes
No
Do you wear contact lenses?
Yes
No

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
 
(Please click below to draw/upload sign)
(Your IP Address : )
I have answered all the above questions

Place a mark on 'Yes' or 'No' to indicate if you have had any of the following

Bad breath
Yes
No
Bleeding gums
Yes
No
Blisters on lips or mouth
Yes
No
Burning sensation on tongue
Yes
No
Chew on one side of mouth
Yes
No
Cigarette, pipe or cigar smoking
Yes
No
Clicking or popping jaw
Yes
No
Dry mouth
Yes
No
Fingernail biting
Yes
No
Food collection between the teeth
Yes
No
Foreign objects
Yes
No
Grinding teeth
Yes
No
Gums swollen or tender
Yes
No
Jaw pain or tiredness
Yes
No
Lip or cheek biting
Yes
No
Loose teeth or broken fillings
Yes
No
Mouth breathing
Yes
No
Mouth pain, brushing
Yes
No
Orthodontic treatment
Yes
No
Pain around ear
Yes
No
Periodontal treatment
Yes
No
Sensitivity to cold
Yes
No
Sensitivity to heat
Yes
No
Sensitivity to sweets
Yes
No
Sensitivity when biting
Yes
No
Sores or growths in your mouth
Yes
No
I have answered all the above questions

X-RAY CONSENT FORM

During your examination, the doctor may feel that x-rays/pictures will be needed in order to diagnose your condition. We would like to make you aware that x-rays may be required in order to administer treatment. In order to perform x-rays/pictures on any patient our office requires the patients consent for such tests to be performed.

Please Choose One:

I understand that my doctor may need x-rays/pictures in order to diagnose my condition. I give my permission of all needed diagnostic tests and for such items be used for purposes of research, education or publication in professional journals.
I understand that my condition may require my doctor to take x-rays to further diagnose my symptoms. I choose to not have any x-rays/pictures at this time and release my doctor of all liabilities.
SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

Females Only:

I understand that if I am pregnant and have x-rays taken which expose my lower torso to radiation, it is possible to injure the fetus.

I have been advised that ten (10) days following onset of menstrual period are generally considered to be safe for x-ray exams.

With those factors in mind, I am advising my doctor that:

I am pregnant
Yes
No
I don't know
I could be pregnant
Yes
No
I don't know
SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

Patient Acknowledgement and Consent Form

Effective April 14, 2003, the new federal law known as the Health Insurance Portability and Accountability Act of 1996 ('HIPAA') requires that this office comply with certain rules regarding the maintenance of the privacy of yourInformation that we have collected and will collect in the future.

To comply with one of the HIPAA requirements,Ricky L Larson DDS PLLC is providing you with a copy of our Notice of Privacy Practices. This Notice of Privacy Practices contains the information that HIPAA requires us to disclose regarding our privacy practices. Existing Texas law requires(In addition to our attempt to obtain your written acknowledgement,discussed above) us to first obtain your written consent prior to disclosing any of your information except for our disclosures in connection with:a defense to a claim challenging our professional competence; a review of the entity's functions;a claim for payment of fees; a third party payer's examination of our records;a court order as part of a criminal investigation; an identification of a dead body;a licensure investigation; or a child abuse/neglect investigation

In some instances,it may be necessary for us to make disclosures of your informationin connection with your treatment. For example,we may make a referralto or consult with another covered entity for testing or otherwise makedisclosures of your informationin connection with providing or coordinating your treatment.

Patient Acknowledgement

Please sign this form below under the heading "acknowledgment" to acknowledge that you have today received a copy of our Notice of Privacy Practices.

I acknowledge that I have today received a copy of the Notice of Privacy Practices.

SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

Patient Consent & Authorization

Please sign this form below under the heading "Consent" to consent to our disclosures of your information that we deem necessary inorder to provide you with proper treatment.

I consent to your disclosures of my information, which you deem are necessary in connection with my treatment

Communication with laboratories or other specialists for any medical treatment, consultations, and educational purposes or for any other purpose deemed appropriate by Ricky L Larson DDS PLLC.

SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

OFFICE POLICIES

We would like to welcome you to our office, and are happy you have chosen us for your dental care. Our goal is to provide you with the best possible care available. In order to meet this goal, we need your assistance and understanding of our office policies. Our Financial Policy is a necessary part of assuring the financial resources needed to maintain this vital health care facility for our patients.

Insurance Companies

We are here to help answer any questions you may have regarding your insurance coverage and payments. However, your insurance is a contract between you, your employer, and the insurance company. We are not a party to that contract. Most companies base insurance payments on a Usual and Customary Rate (UCR). Our fees generally fall within the UCR range; unfortunately, some insurance companies reimburse on a fee schedule, which may bear no relationship to the current standard and cost of care in this area. You will be responsible for our charges regardless of the company's arbitrary determination of the UCR. As a courtesy to our patients, we will file your claims directly to your primary insurance carrier. If you have secondary insurance,we will be happy to provide you with the necessary information for you to file.

Financial Responsibility

Full payment of services is due at the time of your visit. lf you have a dental insurance plan, co-payment and deductible amounts will be collected at the time of the visit. ln the event that it is an uncovered procedure, or if your maximum has been met for the year, the full amount will be due at your visit. We accept cash, checks, Visa, MasterCard, American Express and Discover. We also offer Care Credit for financing options.

Broken Appointments

Thank you for choosing us as your dental health care provider. We believe it is important that our patients fully understand our financial and office policies, so we may concentrate on you and your dental needs. It is your responsibility to notify us of any changes in your account status (i.e. changes of address, work and home phone numbers and insurance infonnation.) Our business office is available during regular business hours, and we welcome any questions you may have regarding our policies.

I have read the above, and I understand and agree to this financial policy.
SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

PATIENT AUTHORIZATION TO RELEASE RECORDS

I authorize

to release information regarding my dental health, or the dental health of my child (ren). I understand that the above information and any current x-rays will be transferred to Dr. Rick Larson at my request.

SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )
Thank you for visiting Rick Larson, D.D.S. We want your visit to be pleasant and comfortable. Please help us by completing this form
Patient Information

Personal Details

Title:           First Name:           Last Name:           Middle Initial:          
Birthdate:           Gender:          
Address:           City:           State:           Zip Code:          
Email Address:           Occupation:          
Patient Employer/School:           Employer/School Address:           Employer/School Phone:           How did you hear about our office?          

How do we contact you?

Home Phone:           Work Phone:           Ext:           Alt. Phone:          
Spouse's Work:           Best time and place to reach you         

IN CASE OF EMERGENCY, CONTACT (Specify someone who does not live in your household.)

Name:           Relationship:           Home Phone:           Work Phone:          
 
 
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

Spouse Information

Spouse Name: Birthdate Social Security Number: Spouse's Employer: Who may we thank for referring you?:
Are You Married? Yes No

Dental Insurance Information

Who is responsible for this account?:           Relationship to Patient:          
Insurance Company:           Group #:           Employee Name :          Employer Name :          Insurance Company Name:           Insurance Co.Phone:           Subscriber Name:           Subscriber ID#:          Subscriber DOB:          
 
 
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS
Do You have Primary Insurance? Yes No

Additional Insurance Information

Subscriber's Name:           Birthdate:           Social Security Number:           Relationship to Patient:           Insurance Company:           Group #:           company's phone number:          

ASSIGNMENT AND RELEASE

I certify that I, and/or my dependent(s), have insurance coverage with 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.

 
 
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS
Name of Patient, Parent, Guardian or Personal Representative:           Relationship to Patient :          
Do You have Secondary Insurance? Yes No
Medical History
Physician's Name: Date of last visit:
Have you ever used a bisphosphonate medication? Common brand names are Fosamax, Actonel, Atelvia, Didronel, Boniva?
Yes
No
Have you ever taken any of the group of drugs collectively referred to as "fen-phen"? These include combinations of Ionimin, Adipex, Fastin(brand names of phentermine), Pondimin (fenfluramine) and Redux(dexfenfluramine)?
Yes
No
Are you a woman?
Yes
No
Pregnant
Nursing
Taking oral contraceptives
None
Are you allergic to any of the following?
Aspirin Local anesthetics Barbiturates (Sleeping Pills) Penicillin
Codeine Sulfa Iodine Latex
Other
If Other, Please Specify:
Has there been any change in your health since your last dental appointment? Yes No
For what conditions?          
Are you taking any new medications?           If so,what?          
Place a mark on 'Yes' or 'No' to indicate if you had any of the following
AIDS/HIV Positive Anemia Arthritis, Rheumatism
Artificial Heart Valves Artificial Joint Asthma
Back Problems Bleeding abnormally, with extractions or surgery Blood Disease
Cancer Chemical Dependency Chemotherapy
Circulatory Problems Congenital Heart Lesions Cortisone medicine
Cough, persistent or bloody Diabetes Emphysema
Epilepsy Fainting or Dizziness Glaucoma
Headaches Heart Murmur Heart Pace Maker
Hepatitis Herpes High Blood Pressure
If Hepatitis yes, please enter the type:
Jaundice Jaw Pain Kidney Disease
Liver Disease Low Blood Pressure Mitral Valve prolapse
Nervous Problems Pacemaker Psychiatric Care
Radiation Treatment Respiratory Disease Rheumatic Fever
Scarlet Fever Shortness of Breath Sinus Trouble
Skin Rash Special Diet Stroke
Swollen Feet or Ankles Swollen Neck Glands Thyroid Problems
Tonsillitis Tuberculosis Tumors or Growths on head or neck
Ulcer Venereal Disease Weight Loss, unexplained
Do you wear contact lenses?
Yes
No
List any medications you are currently taking and the correlating diagnosis:     Pharmacy Name:     Phone Number    

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.

 
 
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS
Dental History
Reason for today's visit:           Former dentist:           City:           State:          
Date of last dental visit:           Date of last X-rays:          
Place a mark on 'Yes' or 'No' to indicate if you had any of the following
Bad breath Bleeding gums
Blisters on lips or mouth Burning sensation on tongue
Chew on one side of mouth Cigarette, pipe or cigar smoking
Clicking or popping jaw Dry mouth
Fingernail biting Food collection between the teeth
Foreign objects Grinding teeth
Gums swollen or tender Jaw pain or tiredness
Lip or cheek biting Loose teeth or broken fillings
Mouth breathing Mouth pain, brushing
Orthodontic treatment Pain around ear
Periodontal treatment Sensitivity to cold
Sensitivity to heat Sensitivity to sweets
Sensitivity when biting Sores or growths in your mouth
How often do you floss?           How often do you brush?          


X-RAY CONSENT FORM

Patient Name          

During your examination, the doctor may feel that x-rays/pictures will be needed in order to diagnose your condition. We would like to make you aware that x-rays may be required in order to administer treatment. In order to perform x-rays/pictures on any patient our office requires the patients consent for such tests to be performed.

Please Choose One:

I understand that my doctor may need x-rays/pictures in order to diagnose my condition. I give my permission of all needed diagnostic tests and for such items be used for purposes of research, education or publication in professional journals.
I understand that my condition may require my doctor to take x-rays to further diagnose my symptoms. I choose to not have any x-rays/pictures at this time and release my doctor of all liabilities.
The information on this page is correct to the best of my knowledge.
 
 
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

Females Only:

I understand that if I am pregnant and have x-rays taken which expose my lower torso to radiation, it is possible to injure the fetus.

I have been advised that ten (10) days following onset of menstrual period are generally considered to be safe for x-ray exams.

With those factors in mind, I am advising my doctor that:

I am pregnant
Yes
No
I don't know
I could be pregnant
Yes
No
I don't know
The information on this page is correct to the best of my knowledge.
 
 
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

Patient Acknowledgement and Consent Form

Effective April 14, 2003, the new federal law known as the Health Insurance Portability and Accountability Act of 1996 ('HIPAA') requires that this office comply with certain rules regarding the maintenance of the privacy of yourInformation that we have collected and will collect in the future.

To comply with one of the HIPAA requirements,Ricky L Larson DDS PLLC is providing you with a copy of our Notice of Privacy Practices. This Notice of Privacy Practices contains the information that HIPAA requires us to disclose regarding our privacy practices. Existing Texas law requires(In addition to our attempt to obtain your written acknowledgement,discussed above) us to first obtain your written consent prior to disclosing any of your information except for our disclosures in connection with:a defense to a claim challenging our professional competence; a review of the entity's functions;a claim for payment of fees; a third party payer's examination of our records;a court order as part of a criminal investigation; an identification of a dead body;a licensure investigation; or a child abuse/neglect investigation

In some instances,it may be necessary for us to make disclosures of your informationin connection with your treatment. For example,we may make a referralto or consult with another covered entity for testing or otherwise makedisclosures of your informationin connection with providing or coordinating your treatment.

Patient Acknowledgement

Please sign this form below under the heading "acknowledgment" to acknowledge that you have today received a copy of our Notice of Privacy Practices.

I acknowledge that I have today received a copy of the Notice of Privacy Practices.

Patient Name          
 
 
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

Patient Consent & Authorization

Please sign this form below under the heading "Consent" to consent to our disclosures of your information that we deem necessary inorder to provide you with proper treatment.

I consent to your disclosures of my information, which you deem are necessary in connection with my treatment

Communication with laboratories or other specialists for any medical treatment, consultations, and educational purposes or for any other purpose deemed appropriate by Ricky L Larson DDS PLLC.

Patient Name          
 
 
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

OFFICE POLICIES

We would like to welcome you to our office, and are happy you have chosen us for your dental care. Our goal is to provide you with the best possible care available. In order to meet this goal, we need your assistance and understanding of our office policies. Our Financial Policy is a necessary part of assuring the financial resources needed to maintain this vital health care facility for our patients.

Insurance Companies

We are here to help answer any questions you may have regarding your insurance coverage and payments. However, your insurance is a contract between you, your employer, and the insurance company. We are not a party to that contract. Most companies base insurance payments on a Usual and Customary Rate (UCR). Our fees generally fall within the UCR range; unfortunately, some insurance companies reimburse on a fee schedule, which may bear no relationship to the current standard and cost of care in this area. You will be responsible for our charges regardless of the company's arbitrary determination of the UCR. As a courtesy to our patients, we will file your claims directly to your primary insurance carrier. If you have secondary insurance,we will be happy to provide you with the necessary information for you to file.

Financial Responsibility

Full payment of services is due at the time of your visit. lf you have a dental insurance plan, co-payment and deductible amounts will be collected at the time of the visit. ln the event that it is an uncovered procedure, or if your maximum has been met for the year, the full amount will be due at your visit. We accept cash, checks, Visa, MasterCard, American Express and Discover. We also offer Care Credit for financing options.

Broken Appointments

Thank you for choosing us as your dental health care provider. We believe it is important that our patients fully understand our financial and office policies, so we may concentrate on you and your dental needs. It is your responsibility to notify us of any changes in your account status (i.e. changes of address, work and home phone numbers and insurance infonnation.) Our business office is available during regular business hours, and we welcome any questions you may have regarding our policies.

 
 
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS
I have read the above, and I understand and agree to this financial policy.

PATIENT AUTHORIZATION TO RELEASE RECORDS

I authorize Dr.           to release information regarding my dental health, or the dental health of my child (ren). I understand that the above information and any current x-rays will be transferred to Dr. Rick Larson at my request.

 
 
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS
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