ID:

First Name:

Patient ls:

Chart lDr

PATIENT REGISTRATION

Last Name: Middle lnit ial :

I Pol icy Holder

I Responsible Party

Preferred Name:

-Responsible Party (if someone other than the patient)

First Name: Last Name: Middle Init ial :

Address:

City, State, Zip:

Home Phone:

Address 2:

Pager:

Work Phone:

Soc Sec:

Ext:

Birth Date: Drivers Lic:

O Responsible Party is also a Policy Holder for Patient Q erimary Insurance Policy Holder O Secondary Insurance Policy Holder

Address:

City:

Address 2:

Home Phone: Work Phone:

State / Zip:

Ext:

Marital Status: Q Married Q Singte

Pager

Cellular:

Q Divorced Q Separated Q widowed

Drivers Lic:

Sex: e n/late Q Female

Birth Date: _ Age: Soc. Sec:

E-mail :

Section 2

f-l I would like to receive correspondences via e-mail

Section 3

Employment Status: Q futt Time

Student Status: Q fuil Time

Medicaid lD:

Employer lD:

Canier lD:

Q eart time Q Retireo

Q Part Time

Pref. Dentist:

Pref. Pharmacy;

Emergency Contact:

Emergency Phone:

Refened By:

Previous Dentist:

Pref. Hyg.:

r Primary Insurance Information

Name of Insured:

Insured Soc. Sec:

Employer:

Insured Birth Date:

Relat ionship to Insured:O Sef Q spouse Q crrito Q otner

Ins. Company:

Address:

Address 2:

; city,State,Zip:

.00

Address:

Address 2:

I City,State,Zip:

I Rem. Benefits:I

.00 Rem. Deduct:

; Secondary Insurance Information

I Name nf lncrrrcd'I Name of Insured:

Insured Soc. Sec:

Employer:

Insured Birth Date:

Relationship to Insured:Q Self Q spouse Q cniu Q ottrer

Ins. Company:

Address:

Address 2:

City,State,Zip:

Address:

Address 2:

City,State,Zip:

Rem. Benefits: 00 Rem" Deduct: 00

Alpine Family Dental

MEDICAL HISTORY

PATIENT NAME Birth Date

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your e;-" t"tr"*n Oro*"* 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? Q ves Q tto

Have you ever been hospitalized or had a major operationZ Q Ves Q ruo

Have you ever had a serious head or neck injury? Q Ves Q tto

Are you taking any medications, pills, or drugs? Q Ves Q No

Do you take, or have you taken, Phen-Fen or Redux? Q Ves Q fuo

Have you evertaken Fosamax, Boniva, Actonel or any ^ , , . ,

other."medications containing bisphosphonatssi (, Yes L) No

Are you on a special diet? Q Yes QDo you use tobacco? Q ves Q

Do you use controlled substances? Q ves Q

Women: Are you

! Pregnant/Trying to get pregnant?

! taking oral contraceptives?

lf yes, please explain:

lf yes, please explain:

lf yes, please explain:

lf yes, please explain:

No

No

No

! vtetat

f Nursing?

Are you allergic to any of the following?..**

! Aspirin ! Penicil l in ! Codeine ! Acrylic ; , ; ; ; I Local Anesthetics I sura Drugs

I Ottrer lf yes, please explain:

n AtDS/Htv Positive

n Alzheimer's Disease

! Anaphylaxis

! Anemia

f, Angina

I Arthritis/cout

f, Rrtiticiat HeartValve

f nrtiticiat Joint

I astnma

I Blood Disease

I aooo Transfusion

f Breathing Problem

L l tsrurse casily

I cancer

f Chemotherapy

f Chest Pains

! coto Sores/Fever Blisters

! Congenital Heart Disorder

! Convulsions

! Cortisone Medicine

! oiabetes

I Drug Addiction

n EasilyWinded

I Emphysema

I Epilepsy or Seizures

! Excessive Bleeding

I ExcessiveThirst

I fainting Spells/Dizziness

I Frequent Gough

f Frequent Diarrhea

! Frequent Headaches

E Genital Herpes

I claucoma

I Hay Fever

! HeartAttacuFailure

! Heart Murmur

! Heart Pacemaker

n Hemophil ia

n Hepatitis A

n Hepatitis B or C

I Herpes

I Hign Blood Pressure

f Hign Cholesterol

I Hives or Rash

! Hypoglycemia

! lrregular Heartbeat

! xioney Problems

! Leukemia

! Liver Disease

I Low Blood Pressure

f Lung Disease

! Osteoporosis

! eain in Jaw Joints

! Parathyroid Disease

I Psychiatric Care

! Radiation Treatments

n Recent Weight Loss

n Renal Dialysis

! Rheumatic Fever

n Rheumatism

! Scarlet Fever

! Sningles

! sicrte cett Disease

n sinus Trouble

n Spina Bifida

n Stomach/lntestinal Disease

f, strot<e .l

I Swelling of Limbs

n Thyroid Disease

E Tonsillitis! Tuberculosis

! Tumors or Growths! ulcers

! Venereal Disease

n Yellow Jaundice

! Heart Trouble/Disease tr Mitral Valve Prolapse

Haveyoueverhadanyser iousi l lnessnot l is tedabove?Q YesQ No l f yes,pleaseexplain:

Comments:

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can bedangerous to my (or patient's) health. lt is my responsibility to inform the dental office of any changes in medical status.

SIGNATURE OF PATIENT. PARENT. or GUARDIAN DATE

Alpine Family Dental 101 Westview Park Place

Kalispell MT 59901 (406) 752-1107

Dental Anxiety Scale

DENTAL ANXIETY SCALE

This form is designed to inform us of your individual needs, so you may have a comfortable, pleasant experience in our office.

Please choose the most appropriate answer:

1. If you had to go to the dentist tomorrow, how would you feel about it?

A) I would look forward to it as a reasonable, enjoyable experience.

B) I wouldn’t care one way or the other.

C) I would be a little uneasy about it.

D) I would be afraid that it would be unpleasant and painful.

E) I would be very frightened of what the dentist might do.

2. When you are waiting In the dentist’s office for your turn in the chair, how do you feel?

A) Relaxed

B) A little uneasy

C) Tense

D) Anxious

E) So anxious that I sometimes break out in a sweat or almost feel physically sick

3. When you are in the dentist’s chair, waiting while he gets his drill ready to begin working on your teeth, how do you

feel?

A) Relaxed

B) A little uneasy

C) Tense

D) Anxious

E) So anxious that I sometimes break out in a sweat or almost feel physically sick

4. You are in the dentist’s chair to have your teeth cleaned. While you are waiting and the hygienist is getting out the

instruments that will be used to clean your teeth around the gums, how do you feel?

A) Relaxed

B) A little uneasy

C) Tense

D) Anxious

E) So anxious that I sometimes break out in a sweat or almost feel physically sick

On a scale of 0 to 10, where 0 is so relaxed you could fall asleep and 10 is the point when you are so fearful you might faint,

become sick, or run out of the treatment room, please rate the flowing:

1. ___ Sitting in the dental reception room 8. ___ Have a tooth drilled

2. ___Smelling the “smell” of a dental office 9. ___Seeing the dental probes or instruments

3. ___Sitting up in a dental chair 10. ___having the dental instruments manipulated

4. ___Reclining in a dental chair in your mouth

5. ___Seeing the needle and syringe for anesthesia 11. ___The dentist walks into the treatment room

6. ___Receiving the anesthetic injection 12. ___Having your teeth cleaned

7. ___Hearing the noise of the dentist’s drill 13. ___Having dental x-rays taken

Have you ever experienced nitrous oxide (gas) in a dental office? ___ Yes ___ No

Your Name: _______________________________________________ Today’s date: ___________________________

 

Financial and Appointment Agreement 

Alpine Family Dental 

101 Westview Park Place 

Kalispell, MT 59901 

 

 

I understand that I am financially responsible for all services rendered at this office.   

I hereby authorize Gregory D. Eller DMD PC (dba Alpine Family Dental) to affix my name to all insurance 

submissions, documents, and/or information requested by company(s) relating to any health benefits 

due to my dependents and myself.  I authorize insurance payments to be sent directly to this office.  I 

understand that if insurance sends payment to me directly, I am required to pay at the time services are 

rendered.  I agree to be held responsible for all charges and services not paid by my insurance company.   

Should my account become delinquent I will be held responsible for all costs associated with collection 

including collection agency fees.  I also authorize the use of any information provided by me on my 

patient registration form to secure payment from insurance companies or collection agencies.  

I understand that when I schedule an appointment it is reserved exclusively for me and I assume the 

responsibility to maintain my appointment.  If I am unable to maintain my appointment I understand 

that I'm required to give a 48 hour notice of cancellation. If I arrive late I understand I may not be seen 

that day and my tardiness will be considered a short notice cancelled appointment.  I understand if I am 

habitually late, miss or short notice cancel appointments, I may be dismissed from the practice.  

No showed or short notice cancelled appointments may result in a $50.00 broken appointment fee. 

Phone call, Text Message and Email reminders are solely a courtesy.   

Please select how you would like to receive your courtesy reminder:  

Phone call         

Text Message         

Email            

 

Signature of patient or responsible party:                 Date:  

 

 

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES Alpine Family Dental ‐ Gregory D. Eller, DMD PC 

 

You may refuse to sign this acknowledgement but, in refusing we will not be allowed to process your 

insurance claims.  

Date:        

The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for Alpine 

Family Dental (Gregory D. Eller, DMD PC). A copy of the signed, dated document shall be effective as the original. 

MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR 

RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTORS IN THE FUTURE. 

  Please print patients/your name            Please sign your name 

 

Legal guardian              Relation to patient 

 

 

PLEASE LIST ANY OTHER PEOPLE WHO CAN HAVE ACCESS TO YOUR DENTAL INFORMATION:  

(This includes spouse, partner, step parents, parents (when patient is over age 18), grandparents and any care takers who can have access to 

this patient's records):  

Name:               Name:  

Name:               Name:              

Name:               Name:            

     

Special Requests:  

 

Office Use Only:  

As privacy officer, I attempted to obtain the patient's (or legal guardians) signature on this acknowledgement but did not because:  

  It was emergency treatment              

  I could not communicate with the patient 

  The patient refused to sign 

  The patient was unable to sign because 

  Other (please describe)             Signature of Privacy Officer