Patients Forms

Please either fill out and submit the patient form below or print them out and bring them to your appointment. Patient Forms

Patient Information
Name*
First Middle Last
Address*
Street City State ZIP
Home Phone*
Cell Phone*
Work Phone
Birth Date*
MM slash DD slash YYYY
Social Security #*
Whom may we thank for referring you to our office?
Email*
Date
MM slash DD slash YYYY
Responsible Party Information
Name*
First Middle Last
Marital Status*
Address*
Street City State ZIP
How long at this address
Home Phone*
Work Phone
Previous Address (if less than 3yrs.)
Street City State
Social Security #*
Driver's License #
Birth Date*
MM slash DD slash YYYY
Relationship to Patient
Employer
Occupation
No. Years Employed
Spouse's Name
First Middle Last
Spouse's Employer
Occupation
No. Years Employed
Insurance Information
Insured's Name
Insured's Soc. Sec. #
Insurance Company
Insurance Company Phone #*
Insured's DOB
MM slash DD slash YYYY
Address
City, State
Phone*
ID #
Group No.
Local No.
Do you have secondary coverage?*
- Yes
- No
Insured's Name
Insured's Soc. Sec. #
Insurance Company
Group No.
Local No.
Insured's Employer
Emergency Information
Name of nearest relative not living with you
Complete Address
Phone Number
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.
Are you under a physician's care now?
- Yes
- No
If yes
Have you ever been hospitalized or had a major operation?
- Yes
- No
If yes
Have you ever had a serious head or neck injury?
- Yes
- No
If yes
Are you taking any medications, pills, or drugs?
- Yes
- No
If yes
Do you take, or have you taken, Phen-Fen or Redux?
- Yes
- No
If yes
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
- Yes
- No
If yes
Are you on a special diet?
- Yes
- No
Do you use tobacco?
- Yes
- No
Do you use controlled substances?
- Yes
- No
If yes
Women: Are you...
- Pregnant/Trying to get pregnant?
- Nursing
- Taking oral contraceptives?
Are you allergic to any of the following?
- Aspirin
- Metal
- Penicillin
- Latex
- Codeine
- Sulfa Drugs
- Acrylic
- Local Anesthetics
- Other
If yes
Do you have, or have you had, any of the following?
- AIDS/HIV Positive
- Alzheimer's Disease
- Anaphylaxis
- Anemia
- Angina
- Arthritis/Gout
- Artificial HeartValve
- Artificial Joint
- Asthma
- Blood Disease
- Blood Transfusion
- Breathing Problems
- Bruise Easily
- Cancer
- Chemotherapy
- Chest Pains
- Cold sores/Fever Blisters
- Congenital Heart Disorder
- Convulsions
- Cortisone Medicine
- Diabetes
- Drug Addiction
- Easily Winded
- Emphysema
- Epilepsy or Seizures
- Excessive Bleeding
- Excessive Thirst
- Fainting Spells/Dizziness
- Frequent Cough
- Frequent Diarrhea
- Frequent Headaches
- Genital Herpes
- Glaucoma
- Hay Fever
- Heart Attack/Failure
- Heart Murmur
- Heart Pacemaker
- Heart Trouble/Disease
- Hemophilia
- Hepatitis A
- Hepatitis B or C
- Herpes
- High Blood Pressure
- High Cholesterol
- Hives or Rash
- Hypoglycemia
- Irregular Heartbeat
- Kidney Problems
- Leukemia
- Liver Disease
- Low Blood Pressure
- Lung Disease
- Mitral Valve Prolapse
- Osteoporosis
- Pain In Jaw Joints
- Parathyroid Disease
- Psychiatric Care
- Radiation Treatments
- Recent Weight Loss
- Renal Dialysis
- Rheumatic Fever
- Rheumatism
- Scarlet Fever
- Shingles
- Sickle Cell Disease
- Sinus Trouble
- Spina Bifida
- Stomach/Intestinal Disease
- Stroke
- Swelling of Limbs
- Thyroid Disease
- Tonsillitis
- Tuberculosis
- Tumors or Growths
- Ulcers
- Venereal Disease
- Yellow Jaundice
Have you ever had any serious illness not listed above?
- Yes
- No
If yes
Comments
Consent*
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.
I agree*
Patient Agreement Form*
I hereby authorize the release of pertinent medical information to my insurance carrier. I am aware that dental insurance coverage varies and, while insurance carriers may use terms such as customary, reasonable, prevailing, etc. to limit their coverage, I am ultimately responsible for payment of all charges for services rendered by Crest Hill Family Dental for myself or my immediate family. If I have insurance, I understand that I will be responsible for any co-payments, deductibles or procedures that may not be considered "a covered procedure" by my insurance company.

Your dental insurance benefit program is a contract between you, your employer and the insurance company. We are not party to that contract. Insurance companies do not dictate the standard of care, but reimburse for a limited number of procedures. Not all dental services are a covered benefit. It is not our responsibility to know your benefits, it is yours. We contact your insurance company to get basic benefit information, so that we can give an estimated co-pay amount on your treatment plan. However, your insurance company will not guarantee exact amounts, therefore the co-payment amount we provide is only an estimate, not a guarantee. The only insurance company that we are contracted with as a preferred provider and are subject to their fee schedule, is Delta Dental. We do submit to all insurance companies that allow a member to choose the Dentist that they would like to see. Remaining amounts are subject to balance billing as per the insurance company guidelines.

I understand and agree that if I fail to keep any scheduled appointment, and do not give at least 48 hours notice, I will be charged one half of my scheduled anticipated appointment charges. I understand that I am solely responsible for this missed appointment fee and it will not be billed to my insurance company.
I agree
Consent*
If you are here as a new patient a comprehensive dental examination, appropriate x-rays and a professional dental cleaning will be performed, if appropriate. At that time a comprehensive dental treatment plan will be completed and the associated procedures and fees will be discussed at that time.

Payment options are cash, Visa or MasterCard, Discover, American Express, check, or debit card. Payment plans are offered solely through CareCredit.

CareCredit is another payment option that our office offers. It also involves an application process that can be done online at www.carecredit.com, in our office after completing a standard application or by calling 1-800-365 8295 and utilizing the automated phone application process. Once approved there are 6 and 12 month interest free payment options. Extended payment plans are also available which are based on 14.90% APR. (Subject to change) Information on this option is always available at our office.

There is a 3.0% (36% APR) monthly late charge assessed on all balances after 60 days past due. Checks, which are declared non-sufficient funds, will be charged a $25.00 service fee. Also, the undersigned agrees to pay a collection fee of 50% of the total owed when sent to collection, all attorney fees and court costs incurred by the creditor.

I have read and understand the above paragraphs in their entirety and all information provided is correct.
I agree*
Notice of Privacy Practices Acknowledgement*
I UNDERSTAND THAT, UNDER THE Health Insurance Portability & Accountability Act of 1996 ("HIPAA"), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
- Conduct, plan and direct my treatment and follow- up among the multiple healthcare providers who may be involved in the treatment directly and indirectly.
- Obtain payment from third- party payers.
- Conduct normal healthcare operations such as quality assessments and physician certifications.
I have received, read and understand your NOTICE OF PRIVACY PRACTICES containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its NOTICE OF PRIVACY PRACTICES from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the NOTICE OF PRIVATE PRACTICES.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.
I agree
We kindly request that you provide your email address, so that we may confirm your appointment with Dr. Raia or Pamela our hygienist. Thank you for understanding our effort to enhance our communication with our patients.

We will also be providing brief newsletters and monthly cosmetic promotions including Lumineers, in office whitening or Snap-On specials. If you would prefer not to be contacted regarding our monthly emails, please check NO below.

Thank you for your understanding in our continuing effort to communicate with our patients in the most effective way possible.

Sincerely,
Thomas J. Raia, D.D.S.
Patient Name
Address
Cell Phone*
Birth Date
MM slash DD slash YYYY
Email
I prefer not to receive emails or special offers.
- No
Missed Appointments*
In today's ever demanding schedule that we all navigate, it is only natural that at times we may forget our dental appointment. In our offices best attempts to reschedule missed appointments we do expect the SECOND appointment to be maintained.

To reschedule a missed appointment, your co-payment must be paid if insurance is involved, for the appointment to be rescheduled. If no insurance is involved, your entire anticipated treatment cost must be paid for your appointment to be rescheduled.

If the SECOND appointment is missed your co-payment or payment in full will be forfeited to compensate for the previously missed appointments. Our intention is to provide the care that has been advised with your initial appointment and NOT to forfeit your payment toward treatment.

Our goal is to provide your dental care with the proper scheduling time necessary for that appointment. Maintaining dental appointments are important to achieve this goal. Thank you for your understanding and we look forward to helping provide your dental care.
I agree.
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Patient Information

Responsible Party Information

Insurance Information

Emergency Information

Medical History

Crest Hill Family Dental

Crest Hill
Family Dental