New Patients Form 1 2 3 4 Patient InformationPlease complete your new patient registration prior to your first appointment. All of your information will be submitted through our secure portal. First Name*Middle InitialLast Name*Preferred NameDate of Birth* SSNE-mail Address Home Phone*Work PhoneCell PhoneAddress*City, State*Zip Code*Preferred Method of ContactWho may we thank for referring you to our office and what are we seeing you for?In an emergency who should be notified? Please enter Name and Phone NumberRESPONSIBLE PARTY INFORMATION Who is responsible for this account?SelfSpouseParentOther(If self, skip to Employer Information) First NameMiddle InitialLast NamePreferred NameDate of Birth SSNE-mail Address Home PhoneCell PhoneWork PhoneAddressCity, State, Zip Code INSURANCE INFORMATION Do you have dental benefits?YesNoPatient's Relationship to InsuredSelfSpouseChildName of InsuredInsured Date of Birth Insured SSNInsurance Plan NameInsurance PhoneMember ID #Group #EmployerPlease take a moment to inform us of your medical and dental history so that we may care for you more effectively and in such a way that accommodates your overall health and well-being.DENTAL HISTORY Who is your General Dentist? When did you last see him/her?When was your last dental cleaning?Frequency2x/year3x/year4x/yearOtherAre you in discomfort?Reason for visit?Are there any dental concerns that you feel Dr. Clagett should be made aware of? MEDICAL HISTORYWho is your Physician?Last physical examYour Pharmacy's Name, Address, and Phone #Are you currently seeing any medical specialists?YesNoIf yes, please list name and specialtyDo you smoke or use smokeless tobacco (including e-cigarettes)?YesNoIf yes, how much?Have you had a joint or heart valve replacement?YesNoHave you been prescribed antibiotic premedication?YesNo(If yes, please take as prescribed prior to your exam)Do you wear a CPap?YesNoAre you diabetic?YesNoNo Most recent HbA1cDo you have, or have you ever had any of the following medical conditions?Do you have any drug allergies?YesNoList Drug AllergiesCancerYesNoType of Cancer(s)Heart Attack/StrokeYesNoAutoimmune DiseaseYesNoHeart SurgeryYesNoPacemaker/DefibrillatorYesNoDo you take or have you taken bisphosphonates?YesNo(Fosamax, Boniva, Reclast, etc)If yes, drug and dosage?Do you take blood thinners?YesNo(Aspirin, Coumadin, Plavix, etc)If yes, drug and dosage?Are you Pregnant?YesNoIf yes, who is your OB/GYN?Are there any other medical conditions that you have that were not listed? Have you taken any medications in the last 12 months?YesNoMedication NameDosageReason for takingMedication NameDosageReason for takingMedication NameDosageReason for takingAdditional MedicationsBy checking this box By checking this box, I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold Dr. Clagett, or any member of his staff, responsible for any errors or omissions that I have made in the completion of this form. Financial Policy & Dental Benefits Consent I understand that I must pay for my dental care at the completion of each visit. By doing so, I am able to help Clagett Periodontics & Implant Dentistry keep down the cost of my are. I understand that other arrangements can be made with the office manager depend-ing upon special circumstances. An estimate of the charge for any procedure or surgery I may require will be given to me upon re-quest. If I have any dental benefits, Clagett Periodontics & Implant Dentistry will be glad to file the proper forms. I authorize the use of my signature on all insurance submissions. I authorize Clagett Periodontics & Implant Dentistry to release all information neces-sary to secure the payment of benefits, as well as collect payment/reimbursement from my benefits company. I understand that any benefits are considered a method of reimbursing me for fees paid to the doctor and are not a substitute for payment. In the event of non-payment, I will be responsible for all collection costs, attorney's fees, and court costs. By checking this box 2 By checking this box, I acknowledge my understanding the above financial policy and agree with its contents. HIPAA Acknowledgement I understand that I may inspect or copy the protected health information described by this authorization. I understand that at any time, this authorization may be revoked, when the office that receives this authorization receives a written revocation, although that revocation will not be effective as to the disclosure of records whose release I have previously authorized, or where other action has been taken in reliance on an authorization I have signed. I understand that my health care and the payment for my healthcare will not be affected if I refuse to sign this form. I understand that information used or disclosed, pursuant to this authorization, could be subject to re-disclosure by the recipient and, if so, may not be subject to federal or state law protecting its confidentiality. By checking this box 3 By checking this box, I acknowledge my understanding the HIPAA Policy and agree with its contents. Consent for Internet Communication/Records Release I grant Clagett Periodontics* I grant Clagett Periodontics and Implant Dentistry permission to use electronic methods to communicate with my referring dentist, my dental benefits provider and/or any other healthcare provider that Dr. Clagett deems necessary for my care. Signature* This iframe contains the logic required to handle Ajax powered Gravity Forms.