Patient Sign-in

Patient Registration Form

Patient Sign-in
New patient Registration
Medical History
Medical history
Dental History
Dental history

Patient Registration( * mandatory to fill )

How do we contact you?( * mandatory to fill )

In case of emergency, contact( Specify someone who does not live in your household )

Please select below

Do You Have Insurance?
Yes No
Is patient covered by additional Insurance?
Yes No
I have read the above choices

Professional Information

Spouse Information( * mandatory to fill )

Primary Insurance Information( * mandatory to fill )

Assignment and release

I certify that I, and/or my dependent(s), have insurance coverage with and assign directly to Dr. Stafford G. Conely, Jr DDS all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named dentist may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.
SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

Secondary Insurance Information( * mandatory to fill )

Assignment and release

I certify that I, and/or my dependent(s), have insurance coverage with and assign directly to Dr. Stafford G. Conely, Jr DDS all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named dentist may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.
SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

Medical History

Medications

Are you allergic to any of the following?
I have answered all the above questions

Medical History

Have you ever used a bisphosphonate medication? Common brand names are Fosamax, Actonel, Atelvia, Didronel, Boniva.
Yes No
Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine).
Yes No

Do you or have you experienced the following?

AIDS/HIV Positive
Yes
No
Anemia
Yes
No
Arthritis,Rheumatism
Yes
No
Artificial Heart Valves
Yes
No
Artificial Joints
Yes
No
Asthma
Yes
No
Back Problems
Yes
No
Bleeding abnormally, with extractions or surgery
Yes
No
Blood Disease
Yes
No
Cancer
Yes
No
Chemical Dependency
Yes
No
Chemotherapy
Yes
No
Circulatory Problems
Yes
No
Congenital heart Lesions
Yes
No
Cortisone Treatments
Yes
No
Cough, persistent or bloody
Yes
No
Diabetes
Yes
No
Emphysema
Yes
No
Epilepsy
Yes
No
Fainting / Dizziness
Yes
No
Glaucoma
Yes
No
Headaches
Yes
No
Heart Murmer
Yes
No
Heart Problems
Yes
No
Hepatitis Type
Yes
No
Herpes
Yes
No
High Blood Pressure
Yes
No
Jaundice
Yes
No
Jaw pain
Yes
No
Kidney Disease
Yes
No
Liver Disease
Yes
No
Low Blood Pressure
Yes
No
Mitral Value prolapse
Yes
No
Nervous problems
Yes
No
Pacemaker
Yes
No
Psychiatric Care
Yes
No
Radiation Treatments
Yes
No
Respiratory Disease
Yes
No
Rheumatic Fever
Yes
No
Scarlet Fever
Yes
No
Shortness of breath
Yes
No
Sinus Trouble
Yes
No
Skin Rash
Yes
No
Special Diet
Yes
No
Stroke
Yes
No
Swollen Feet or Ankles
Yes
No
Swollen Neck Glands
Yes
No
Thyroid Problems
Yes
No
Tonsillitis
Yes
No
Tuberculosis
Yes
No
Tumor or Growths on head or neck
Yes
No
Ulcer
Yes
No
Venereal Disease
Yes
No
Weight Loss, Unexplained
Yes
No
Do you wear contact lenses?
Yes
No

Women

Are you pregnant?
Yes   No  
Are you nursing?
Yes   No  
Taking birth control pills?    Yes   No
I have answered all the above questions

Reason for today's visit?
Bad breath
Yes
No
Bleeding gums
Yes
No
Blisters on lips or mouth
Yes
No
Burning sensation on tongue
Yes
No
Chew on one side of mouth
Yes
No
Cigarette, pipe, or cigar smoking
Yes
No
Clicking or popping jaw
Yes
No
Dry mouth
Yes
No
Fingernail biting
Yes
No
Food collection between the teeth
Yes
No

Foreign objects
Yes
No
Griding teeth
Yes
No
Gums swollen or tender
Yes
No
Jaw pain or tiredness
Yes
No
Lip or cheeck biting
Yes
No
Loose teeth or broken fillings
Yes
No
Mouth breathing
Yes
No
Mouth pain, brushing
Yes
No
Orthodontic treatment
Yes
No
Pain around year
Yes
No
Periodontal treatment
Yes
No
Sensitivity to cold
Yes
No
Sensitivity to heat
Yes
No
Sensitivity to sweets
Yes
No
Sensitivity when biting
Yes
No
Sores or growths in your mouth
Yes
No

Hippa acknowledgement and consent form

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPPA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

* Conduct, plan and direct my treatment and follow-up care among the multiple healthcare providers who may be involved in that treatment directly or indirectly.

* Obtain payment from designated third-party payers.

* Conduct normal health care operations such as quality assessments or evaluations, and physician certifications.

I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information (available in office in print form or on the office website http://www.staffordconleydds.com). I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practice from time to time and that I may contact this organization at any time at the address below to obtain a current copy of the Notices of Privacy Practices.

I understand that I may request in writing that this organization restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand the organization is not required to agree to my request restrictions, but if the organization does agree, then it is bound to abide by such restrictions.

I understand that I may revoke this consent in writing at any time, except to the extent that the organization has taken action relying on this consent.

SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

Appointment policy

Appointment times are reserved for your care. Any changes in appointment times, canceling with short notice, showing up late, or simply not showing up is very disruptive for our schedule and unfair for our other patients who value prompt treatment and are greatly affected by these changes. We require a minimum notice of 24 hours from your appointment time for any appointment changes. A fee of $35.00 will be assessed for appointments changed without 24 hour advanced notification. This does not mean the day before. We try very hard to maintain our schedule so that all our patients can be treated promptly. We have the right to dismiss any patient with three no show/no call for reserved appointments or without 24hr notice. In addition we may cancel unconfirmed appointments the day before if we are unable to contact you or appointment has not been confirmed by the patient.

Financial Policy

In our efforts to keep dental costs at a minimum while maintaining a high level of professional care, we have established the following payment policies:

  • 1. Payments are due prior to services being render. Deductibles, co-pays and estimated patient fees not covered by insurance will be collected prior to the services rendered. Payment options include cash, check, Visa, Master card or health care financing.
  • 2. Insurance benefits will be accepted provided that verification of eligibility can be made. Verification of eligibility is not a guarantee of payment or an approval of benefits.
  • 3. All fees related to treatment are the full responsibility of the patient. Insurance benefits may vary and are not under the control of this office. Patients will be responsible for fees not reimbursed by the insurance company.
  • 4. Accounts greater than 90 days outstanding will be assessed a monthly finance charge of 18%
  • 5. Accounts greater than 90 days outstanding will be assessed a monthly statement fee of $5.00
  • 6. Accounts greater than 90 days outstanding will be assessed a late fee of $175.00
  • 7. Delinquent accounts will be sent to collections and credit reporting agencies.

I have read and understood the above information and agree with the terms and conditions.

SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )
Thank you for visiting Conley Family Dentistry. We want your visit to be pleasant and comfortable. Please help us by completing this form
Patient Information

Personal Details

Title:     First Name:     Last Name:     Middle Initial:    
Birth Date:     Social Security Number:    
Sex:     Marital Status:    

Address

Street Address:     City:     State:     Zip:    
Home Phone:     Cell Phone:     Work Phone:    
Email Address:     Driver's License:    
Patient Employer/School     Occupation:     Employer/School Address    
Employer/School Phone     Spouse's Name     Birthdate     SS#     Spouse's Employer     Whom may we thank for referring you?    

In case of emergency, contact( Specify someone who does not live in your household )

Name:     Relation:    
Home Phone:     Work Phone:    

Professional Information

Employer Name:     Position:    
Employer Address:     City:     State:     Zip Code:    

Spouse Information

Spouse Name:     Date Of Birth:    
Phone Number:     Employer:    

Dental Insurance

Who is responsible for this account?     Relationship to Patient:     Insurance Company     Group#    
Do You have Primary Insurance? Yes No

Is patient covered by additional insurance? Yes No
Subscriber's Name:     Insured Birth Date:     SS#     Relationship: Insurance Company     Group#    

Assignment and release

I certify that I, and/or my dependent(s), have insurance coverage with and assign directly to Dr. Stafford G. Conely, Jr DDS all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named dentist may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.
 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS
Do You have Secondary Insurance? Yes No
Medical History
Physician's Name:     Date of last visit:    
Have you ever used a bisphosphonate medication? Common brand names are Fosamax, Actonel, Atelvia, Didronel, Boniva.
YES NO
Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine). YES NO
Do you or Have you experienced the following ?
AIDS/HIV Epilepsy Respiratory Disease
Anemia Fainting / Dizziness Rheumatic Fever
Arthritis,Rheumatism Glaucoma Scarlet Fever
Artificial Heart Valves Headaches Shortness of breath
Artificial Joints Heart Murmer Sinus Trouble
Asthma Heart Problems Skin Rash
Back Problems Hepatitis Type
Details :
Special Diet
Bleeding abnormally, with extractions or surgery Herpes Stroke
Blood Disease High Blood Pressure Swollen Feet or Ankles
Cancer Jaundice Swollen Neck Glands
Chemical Dependency Jaw pain Thyroid Problems
Chemotherapy Kidney Disease Tonsillitis
Circulatory Problems Liver Disease Tuberculosis
Congenital heart Lesions Low Blood Pressure Tumor or Growths on head or neck
Cortisone Treatments Mitral Value prolapse Ulcer
Cough, persistent or bloody Nervous problems Venereal Disease
Diabetes Pacemaker Weight Loss, Unexplained
Emphysema Psychiatric Care
Radiation Treatments
Details:
Do you wear contact lenses? Yes No
Women
Are you pregnant? Yes No    
Due date    

Are you nursing? Yes No
Taking birth control pills? Yes No

Medications

List any medications you are currently taking and the correlating diagnosis:     Pharmacy Name     Phone    

Allergies

Are you allergic to any of the following?
Aspirin Local anesthetics Barbiturates (Sleeping Pills) Penicillin
Codeine Sulfa lodine Latex
Others
Details:
Dental History
Reason for today's visit?     Former Dentist     City/State     Date of last dental visit     Date of last dental X-rays    
Bad breath
Yes
No
Bleeding gums
Yes
No
Blisters on lips or mouth
Yes
No
Burning sensation on tongue
Yes
No
Chew on one side of mouth
Yes
No
Cigarette, pipe, or cigar smoking
Yes
No
Clicking or popping jaw
Yes
No
Dry mouth
Yes
No
Fingernail biting
Yes
No
Food collection between the teeth
Yes
No
Foreign objects
Yes
No
Griding teeth
Yes
No
Gums swollen or tender
Yes
No
Jaw pain or tiredness
Yes
No
Lip or cheeck biting
Yes
No
Loose teeth or broken fillings
Yes
No
Mouth breathing
Yes
No
Mouth pain, brushing
Yes
No
Orthodontic treatment
Yes
No
Pain around year
Yes
No
Periodontal treatment
Yes
No
Sensitivity to cold
Yes
No
Sensitivity to heat
Yes
No
Sensitivity to sweets
Yes
No
Sensitivity when biting
Yes
No
Sores or growths in your mouth
Yes
No
How often do you floss?    
How often do you brush?    

Hippa acknowledgement and consent form

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPPA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

* Conduct, plan and direct my treatment and follow-up care among the multiple healthcare providers who may be involved in that treatment directly or indirectly.

* Obtain payment from designated third-party payers.

* Conduct normal health care operations such as quality assessments or evaluations, and physician certifications.

I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information (available in office in print form or on the office website http://www.staffordconleydds.com). I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practice from time to time and that I may contact this organization at any time at the address below to obtain a current copy of the Notices of Privacy Practices.

I understand that I may request in writing that this organization restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand the organization is not required to agree to my request restrictions, but if the organization does agree, then it is bound to abide by such restrictions.

I understand that I may revoke this consent in writing at any time, except to the extent that the organization has taken action relying on this consent.

 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

Appointment policy

Appointment times are reserved for your care. Any changes in appointment times, canceling with short notice, showing up late, or simply not showing up is very disruptive for our schedule and unfair for our other patients who value prompt treatment and are greatly affected by these changes. We require a minimum notice of 24 hours from your appointment time for any appointment changes. A fee of $35.00 will be assessed for appointments changed without 24 hour advanced notification. This does not mean the day before. We try very hard to maintain our schedule so that all our patients can be treated promptly. We have the right to dismiss any patient with three no show/no call for reserved appointments or without 24hr notice. In addition we may cancel unconfirmed appointments the day before if we are unable to contact you or appointment has not been confirmed by the patient.

Financial Policy

In our efforts to keep dental costs at a minimum while maintaining a high level of professional care, we have established the following payment policies:

  • 1. Payments are due prior to services being render. Deductibles, co-pays and estimated patient fees not covered by insurance will be collected prior to the services rendered. Payment options include cash, check, Visa, Master card or health care financing.
  • 2. Insurance benefits will be accepted provided that verification of eligibility can be made. Verification of eligibility is not a guarantee of payment or an approval of benefits.
  • 3. All fees related to treatment are the full responsibility of the patient. Insurance benefits may vary and are not under the control of this office. Patients will be responsible for fees not reimbursed by the insurance company.
  • 4. Accounts greater than 90 days outstanding will be assessed a monthly finance charge of 18%
  • 5. Accounts greater than 90 days outstanding will be assessed a monthly statement fee of $5.00
  • 6. Accounts greater than 90 days outstanding will be assessed a late fee of $175.00
  • 7. Delinquent accounts will be sent to collections and credit reporting agencies.

I have read and understood the above information and agree with the terms and conditions.

 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

Your browser doesn't support signing