Patient Registration

Please allow yourself 10-15 minutes to complete

Complete the form below to register before your appointment. Please allow yourself 10-15 minutes to complete.

Privacy Notice

"*" indicates required fields

First Name*

Last Name*

Middle Initial

Preferred Name

Patient Is

Policy Holder

Responsible Party

Responsible Party (If someone other that the patient)

First Name

Last Name

Middle Initial

Address

Address 2

City, State, Zip

Phone

Work Phone

Extention

Birth Date

Social Security Number

Drivers License

Insurance

Responsible Party is also a Policy Holder for Patient

Primary Insurance Policy Holder

Secondary Insurance Policy Holder

Patient Information

Address*

Address 2

City*

State/Zip*

Phone*

Work Phone

Extention

Sex*

Male

Female

Martial Status*

Married

Single

Divorced

Separated

Widowed

Birth Date*

Age*

Social Security*

Drivers License

Receive Emails

I would like to receive correspondences via email.

Employment Status

Full Time

Part Time

Retired

Student Status

Full Time

Part Time

Medicaid ID

Employer ID

Carrier ID

Preferred Dentist

Preferred Pharmacy

Preferred Hygienist

Primary Insurance Information

Name of Insured

Relationship of Insured

Self

Spouse

Child

Other

Insured Social Security Number

Insured Birth Date

Insured Employer

Insured Address

Insured Address 2

Insured City, State, Zip

Insurance Company

Insurance Company Address

Insurance Company City, State, Zip

Rem. Benefits

Rem. Deduct

Secondary Insurance Information

Name of Insured

Relationship of Insured

Self

Spouse

Child

Other

Insured Social Security Number

Insured Birth Date

Insured Employer

Insured Address

Insured Address 2

Insured City, State, Zip

Insurance Company

Insurance Company Address

Insurance Company City, State, Zip

Rem. Benefits

Rem. Deduct

Medical History

Are you under a physician's care now?*

Yes

If Yes

Have you ever been hospitalized or had a major operation?*

Yes

If Yes

Have you ever had a serious head or neck injury?*

Yes

If Yes

Are you taking any medications, pills, or drugs?*

Yes

If Yes

Do you take, or have you taken, Phen-Fen or Reduc?*

Yes

If Yes

Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?*

Yes

If Yes

Are you on a special diet?*

Yes

Do you use tobacco?*

Yes

Do you use controlled substances?*

Yes

If Yes

Are You*

Pregnant/Trying to get pregnant?

Nursing?

Taking oral contraceptives?

None of the above

Are you allergic to any of the following?*

Aspirin

Metal

Penicillin

Latex

Codeine

Sulfa Drugs

Acrylic

Local Anesthetics

If allergic to anything else please list

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

AIDS/HIV Positive*

Yes

Cortisone Medicine*

Yes

Hemophila*

Yes

Radiation Treatment*

Yes

Alzheimer's Disease*

Yes

Diabetes*

Yes

Hepatitis A*

Yes

Recent Weight Loss*

Yes

Anaphylaxis*

Yes

Drug Addiction*

Yes

Hepatitis B or C*

Yes

Renal Dialysis*

Yes

Anemia*

Yes

Easily Winded*

Yes

Herpes*

Yes

Rheumatic Fever*

Yes

Angina*

Yes

Emphysema*

Yes

High Blood Pressure*

Yes

Rheumatism*

Yes

Arthritis/Gout*

Yes

Epilepsy or Seizures*

Yes

High Cholesterol*

Yes

Scarlet Fever*

Yes

Artificial Heart Valve*

Yes

Excessive Bleeding*

Yes

Hives or Rash*

Yes

Shingles*

Yes

Artificial Joint*

Yes

Excessive Thirst*

Yes

Hypoglycemia*

Yes

Sickle Cell Disease*

Yes

Asthma*

Yes

Fainting Spells/Dizziness*

Yes

Irregular Heatbeat*

Yes

Sinus Trouble*

Yes

Blood Disease*

Yes

Frequent Cough*

Yes

Kidney Problems*

Yes

Spina Bifida*

Yes

Blood Transfusion*

Yes

Frequent Diarrhea*

Yes

Leukemia*

Yes

Stomach/Intestinal Disease*

Yes

Breathing Problems*

Yes

Frequent Headaches*

Yes

Liver Disease*

Yes

Stroke*

Yes

Bruise Easily*

Yes

Genital Herpes*

Yes

Low Blood Pressure*

Yes

Swelling of Limbs*

Yes

Cancer*

Yes

Glaucoma*

Yes

Lung Disease*

Yes

Thyroid Disease*

Yes

Chemotherapy*

Yes

Hay Fever*

Yes

Mitral Valve Prolapse*

Yes

Tonsillitis*

Yes

Chest Pains*

Yes

Heart Attack/Failure*

Yes

Osteoporosis*

Yes

Tuberculosis*

Yes

Cold Sores/Fever Blisters*

Yes

Heart Murmur*

Yes

Pain In Jaw Joints*

Yes

Tumors or Growths*

Yes

Congenital Heat Disorder*

Yes

Heart Pacemaker*

Yes

Parathyroid Disease*

Yes

Ulcers*

Yes

Convulsions*

Yes

Heart Trouble/Disease*

Yes

Psychiatric Care*

Yes

Venereal Disease*

Yes

Yellow Jaundice*

Yes

Have you ever had any serious illness not listed above?*

Yes

If Yes

Comments

Emergency Contact Information*

Release of Information Consent

Patient's Full Name*

Patient's Date of Birth*

Patient's Social Security Number*

Patient's Telephone Number*

Address*

City, State, Zip Code*

I hereby authorize use or disclosure of protected financial, health and dental information about me as described below.*

The following facility is authorized to use or disclose information about me: Insight Dental Associates of 2217 University Dr. N. Fargo, ND 58102

The following person's (or class of persons) may receive disclosure of protected financial, health and dental information about me:

Federal Privacy Regulations*

I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it, and would then no longer be protected by federal privacy regulations.*

Dental Associates*

I may revoke this authorization by notifying Insight Dental Associates in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.*

Name*

Signature of Whom Individual the Information Relates

Today's Date*

Description of Authority to Act for the Individual

If self, leave blank

Date of Birth or Social Security Number*

For Official Use Only

Dental Insurance & Financial Policy Disclosure

FULL PAYMENT for all dental services provided in our office is the responsibility of the patient or patient’s parent or guardian. If you have a dental insurance plan, our office will assist you in submitting claims as a courtesy, but you will be responsible for any difference in fees.

Our office submits insurance electronically every day. It is your responsibility to keep your insurance and personal information current in our files.

Please understand that all insurance plans are not equal. Among the different insurance plans and even within the same company, there are considerable differences in rates and allowances. Because of this our office cannot verbally estimate what your insurance will pay.

If you have concerns about what your insurance will pay, please request a pretreatment estimate before treatment is done. We usually allow 4-6 weeks for a response from the insurance. A letter will be sent to you indicating the estimated amount insurance states they may pay and what your responsibility is. Remember, this is always only an estimate and does not guarantee payment from your insurance. Actual benefits are not determined until the services are completed.

Our office participates as a provider for United Concordia (former BCBS Plans) and Delta Dental Premier. We are not providers for MN Medicaid/MN CARE, and do not submit claims, you will be responsible for payment on the day of service.

I understand that my insurance plan may contribute a portion of the payments due Sandman Family Dentistry, LTD DBA Insight Dental Associates.

Name*

Date*

Acknowledgement Of Receipt Of Notice Of Privacy Practices

**You May Refuse to Sign This Acknowledgement**

I acknowledge that I received a copy of Insight Dental Associates Notice of Privacy Practices.

Name*

Date*

Phone

This field is for validation purposes and should be left unchanged.

Patient Registration

Please allow yourself 10-15 minutes to complete

Responsible Party (If someone other that the patient)

Patient Information

Primary Insurance Information

Secondary Insurance Information

Medical History

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

Release of Information Consent

For Official Use Only

Dental Insurance & Financial Policy Disclosure

Acknowledgement Of Receipt Of Notice Of Privacy Practices

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