Patient Registration: Annapolis Prosthodontic Associates

John P. Davliakos, D.M.D.
Arezoo A. Bahar, D.D.S.
Sara R. Satin, D.M.D., M.S.

Patient’s Registration Form

Home / Patient’s Registration Form

Patient’s Information's

Name of Parent /Partner/ Spouse / Guardian(Circle one)

Address if Different

In case of emergency, whom shall we notify?

Primary Dental Insurance

Secondary Dental Insurance

Primary Care Physician name(s):

Date of your last physician’s visit:

Your current health is? (Check one)

Are you currently under the care of a physician for a medical problem?

Yes No

If yes for what reason(s)?

Have you been hospitalized in the past 5 years?

Yes No

Please list any medications or herbals you are currently taking:

Are you or have you ever taken bisphosphonates (ie: Actonel, Boniva, Fosamax, etc.) for osteoporosis or cancer treatment, either oral or IV?

If Yes, Name of medication

Last dose & frequency

Do you smoke tobacco products in any form?

Yes No

For women: Are you pregnant?

Yes No

Do you require antibiotics before dental treatment?

Yes No

If Yes, for what condition?

List Allergies (penicillin, codeine, Novocain, jewelry, latex, etc.):

Do you have or have you had any of the following medical conditions?

Are you currently experiencing a dental problem

What is the purpose of your visit today?

Who can we thank for referring you to our office?

Do you or have you seen any other dental professionals? Who & what for?

If you are seen in a dental office other than this one, when was your last hygiene appointment?

I hereby give Annapolis Prosthodontic Associates permission to use my images, photographs and/or appearance in pictures, photos, or digital images for uses including but not limited to educational materials in any medium including the internet.

I understand the information that I have given today is correct to the best of my knowledge. I also understand that this information is confidential and it is my responsibility to inform this office of any changes in my medical status. I am directly responsible for payment to this office for professional services rendered to me.

I have read and reviewed a copy of the dental practice’s privacy, security and breach notification policies and procedures. I understand that I should ask our dental practice’s Privacy Official if I have any questions about these policies and procedures.

Cancellation & Financial Policy

We ask for at least 24 hours advance notice for canceling or rescheduling an appointment; otherwise, a $85.00 fee may be assessed to your account. Note; All cancellation fees must be paid prior to scheduling another appointment.

The treatment that is planned for this appointment is specific to you. It is important for you to keep the scheduled dates and times to properly complete your treatment. Your oral health is very important to your overall wellness. Also, your time is a valuable asset. We, therefore, request that you make every effort to keep your scheduled appointment.

Acknowledgement And Release

Insurance

We provide services for our patients with the understanding that they are responsible for payment in accordance with our financial policy. We will prepare and submit forms and reports to assist you in obtaining maximum benefits available, however the dentist’s treatment recommendations or fees are not affected by the presence or absence of insurance benefits. Treatment recommendations are based on your dental needs and desires and are not a reflection of your dental insurance benefits. Your dental benefits are a contract between you, your employer, and the insurance company; therefore, we do not confirm insurance eligibility or predetermine recommended treatment. We are not preferred providers or members or have any association with any insurance organizations.

Collections

In the event the balance becomes more than 60 days overdue, billing may be turned over to an outside collection agency. The responsible party listed above agrees to pay interest, collection and other legal expenses related to collection of fees owed. Waiver of any breach of any time or condition shall not constitute a waiver of any further term or condition.

Patient’s Registration Form

Annapolis Prosthodontic Associates

Patient’s Information's

In case of emergency, whom shall we notify?

Primary Dental Insurance

Secondary Dental Insurance

Medical Information

I hereby give Annapolis Prosthodontic Associates permission to use my images, photographs and/or appearance in pictures, photos, or digital images for uses including but not limited to educational materials in any medium including the internet.

I have read and reviewed a copy of the dental practice’s privacy, security and breach notification policies and procedures. I understand that I should ask our dental practice’s Privacy Official if I have any questions about these policies and procedures.

Cancellation & Financial Policy

We ask for at least 24 hours advance notice for canceling or rescheduling an appointment; otherwise, a $85.00 fee may be assessed to your account. Note; All cancellation fees must be paid prior to scheduling another appointment.

Acknowledgement And Release

Insurance

Collections