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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.

"*" indicates required fields

Patient Is

Responsible Party (If someone other that the patient)
Insurance

Patient Information
Sex*
Martial Status*
Receive Emails
Employment Status
Student Status

Primary Insurance Information
Relationship of Insured

Secondary Insurance Information
Relationship of Insured

Medical History
Are you under a physician's care now?*
Have you ever been hospitalized or had a major operation?*
Have you ever had a serious head or neck injury?*
Are you taking any medications, pills, or drugs?*
Do you take, or have you taken, Phen-Fen or Reduc?*
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?*
Are you on a special diet?*
Do you use tobacco?*
Do you use controlled substances?*
Are You*
Are you allergic to any of the following?*
Do you have or have you had any of the following?
AIDS/HIV Positive*
Cortisone Medicine*
Hemophila*
Radiation Treatment*
Alzheimer's Disease*
Diabetes*
Hepatitis A*
Recent Weight Loss*
Anaphylaxis*
Drug Addiction*
Hepatitis B or C*
Renal Dialysis*
Anemia*
Easily Winded*
Herpes*
Rheumatic Fever*
Angina*
Emphysema*
High Blood Pressure*
Rheumatism*
Arthritis/Gout*
Epilepsy or Seizures*
High Cholesterol*
Scarlet Fever*
Artificial Heart Valve*
Excessive Bleeding*
Hives or Rash*
Shingles*
Artificial Joint*
Excessive Thirst*
Hypoglycemia*
Sickle Cell Disease*
Asthma*
Fainting Spells/Dizziness*
Irregular Heatbeat*
Sinus Trouble*
Blood Disease*
Frequent Cough*
Kidney Problems*
Spina Bifida*
Blood Transfusion*
Frequent Diarrhea*
Leukemia*
Stomach/Intestinal Disease*
Breathing Problems*
Frequent Headaches*
Liver Disease*
Stroke*
Bruise Easily*
Genital Herpes*
Low Blood Pressure*
Swelling of Limbs*
Cancer*
Glaucoma*
Lung Disease*
Thyroid Disease*
Chemotherapy*
Hay Fever*
Mitral Valve Prolapse*
Tonsillitis*
Chest Pains*
Heart Attack/Failure*
Osteoporosis*
Tuberculosis*
Cold Sores/Fever Blisters*
Heart Murmur*
Pain In Jaw Joints*
Tumors or Growths*
Congenital Heat Disorder*
Heart Pacemaker*
Parathyroid Disease*
Ulcers*
Convulsions*
Heart Trouble/Disease*
Psychiatric Care*
Venereal Disease*
Yellow Jaundice*
Have you ever had any serious illness not listed above?*
Release of Information Consent
I hereby authorize use or disclosure of protected financial, health and dental information about me as described below.*
Federal Privacy Regulations*
Dental Associates*
Signature of Whom Individual the Information Relates
If self, leave blank
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.

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.

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