Patient Registration

Welcome to our practice!

Status

The patient is a

Address

Contact

By providing your email, you are consenting to receive appointment reminders and other notifications. You may opt out at any time.

I was refered to the practice by:

Medical Priority – This information will enable us to make any essential contacts

Primary Dental Insurance

Please note that as a courtesy, where possible, we will submit your claim to your primary insurance. Any issues with your insurance company regarding payment are not the responsibility of Framework Dental. Please initial, indicating that you have read and understood the above policy.

Dental History

Please check all that apply. If unsure, please consult with dentist.
Have you ever experienced any of the following jaw problems?
Are you allergic to the any of the following? Please CHECK all that apply.
Have you had or do you currently have _______? Please CHECK all that apply:

Financial Information – If not self, please complete all fields.

Person responsible for this account:

General Release (Please sign after completing medical questionnaire)



I, the undersigned, certify that I have provided an accurate and complete personal and medical- dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my medical – dental history. Should there be any change in either my health status or any other information that I have provided, I will advise this dental office. I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that information provided from or to my medical doctor or another health care provider may be necessary and thereby authorize this dental office to do so via email. I have been advised on the privacy policy of the office and that my personal information will be collected, used and disclosed within the guidelines of the policy. I understand that responsibility for payment of the dental services for myself and my dependents is mine, and I assume responsibility for fees associated with these services.

Person Who is Signing

Signature

© HRI 2020