Audra Hiemstra, D.D.S., P.C.

Patient Registration

First Name: ____________________ MI: _____ Last Name: ______________________

Preferred Name/Nickname:____________ Birth Date: _____________ Sex: � Male � Female

Address: _____________________________________ SSN: _____________________

City: _________________________ State: ____________ Zip: ______________

Home Phone: _____________ Cell Phone:______________ Work Phone: ______________

I would like to receive text messages □ If so, which number? Cell Work Other Best # for Reaching You: Home Work Cell Best time to reach you:______________

E-Mail: ______________________________________________________________

□ I would like to receive correspondences via e-mail

Patient Employer/School: _______________________ Occupation: ________________

Marital Status: □ Minor □ Married □ Single □ Divorced □ Widowed □ Separated

How did you hear about our Office? □ Internet □ Insurance □ Drive By □ Mailers

□ Referring Patient (If so, who? ______________________) □ Other: _____________

PRIMARY DENTAL INSURANCE: (Any Secondary Insurance must be filed by the patient)

Policy Holder: ____________________________ Policy Holder’s DOB: __________

Policy Holder’s SS#: ________________ ____ Relationship to Patient: _____________

Insurance Company: ___________________________________________________

Employer: __________________________________________________________

ID Number: _____________________________ Group #___________________

RESPONSIBLE PARTY:

Name: ____________________________________________________________

Relationship: __________________ Phone Number: ________________________

IN CASE OF EMERGENCY CONTACT:

Name: _____________________________________________________________

Relationship: __________________ Phone Number:_________________________

Dental History Information

Name______________________

Reason for today’s visit: � Exam � Consultation � Emergency

Do you have any dental problems now? � Yes � No If Yes, Explain:

__________________________________________________________________

Are any of your teeth sensitive to: � Hot � Cold � Sweets � Biting or Chewing

PLEASE CHECK ANY OF THE FOLLOWING PROBLEMS:

� Discomfort, Clicking or popping in jaw

� Locking Jaw

� Lost or Broken Fillings

� Broken/chipped teeth

� Stained Teeth

� Sensitive teeth or gums

� Bad Breath

� Loose teeth or Change in bite

� Pain

� Red, swollen or bleeding gums

� Teeth grinding

� Blisters/Cold Sores in or around the mouth

� Other: ___________________________________________________________

Do you require antibiotics before dental treatment? � Yes � No � Don’t Know

Do you like your teeth/smile? Yes No

If not, why? ______________________________________________________

Previous Dentist: __________________________ Phone: ________________________

Last Dental Exam: _____________________ Last Dental X-rays: _____________________

Last Dental Cleaning: ________________________ How often do you brush? ____ per day

How often do you floss? Once a day Once a week Occasionally Never

What type of toothbrush bristles do you use? � Soft � Medium � Hard

WRITTEN FINANCIAL AGREEMENT

Thank you for choosing Tomball Family Dental. As a team we strive to provide the best and most comprehensive dental care available. In order to serve you better, the following financial policies help in understanding the patient’s financial responsibilities. Please read and initial next to each statement.

FULL PAYMENT IS DUE AT THE TIME OF SERVICE.

WE ACCEPT CASH, CHECKS, VISA, MASTERCARD, DISCOVER, CARE CREDIT AND MOST PPO INSURANCES.

_______ Our office will file your insurance as a courtesy to you. We attempt to estimate your portion as

accurately as possible, but please understand you will be responsible for the unpaid balance. Please remember that your dental coverage is a contract between you and your employer’s chosen insurance company. Our office is not party to that contract. _________ We require at least 24 hours for cancellations. Please help us serve you better by keeping your appointments. A cancellation fee of $50.00 will be billed to patients who do not give the required notice. _________ The adult accompanying a minor patient is responsible for full payment at the time of the service. Arrangements should be made for unaccompanied minors to pay at the time of service. _________ We do not participate in any form of DMO, DHMO, HMO, or Medicaid. _________ Unpaid balances will be turned over to collections after 90 days, unless payment arrangements have been made and met. I have read and agree to honor this financial policy. I understand that I am responsible for any portion of my treatment that my insurance does not cover, and I hereby in good faith promise to pay. __________________________________ ______ __________________________ Printed Name Date _________________________________________ Signature of Responsible party