Patient Sign-in

Patient Registration Form

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

Welcome to our office. We appreciate the confidence you place with us to provide dental services. To assist us in serving you, please complete the following form. The information provided on this form is important to your dental health. If there have been any changes in your health, please tell us. If you have any questions, don't hesitate to ask.

Patient Registration( * mandatory to fill )

Is the billing address same as above?
Yes
No

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

Please select below

Are You Married?
Yes No
Do You Have Primary Insurance?
Yes No
Do You Have Secondary Insurance?
Yes No
I have read the above choices

Professional Information

Spouse Information( * mandatory to fill )

Emergency Contact

Primary Insurance Information( * mandatory to fill )

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

Secondary Insurance Information( * mandatory to fill )

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

Previous Medical Visit

Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems 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.

(All questions are required * )

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

Heart Problems
Yes
No
Blood Problems
Yes
No
Allergy Problems
Yes
No
Intestinal Problems
Yes
No
Ulcers
Yes
No
Weight Gain or Loss
Yes
No
Special Diet
Yes
No
Constipation/Diarrhea
Yes
No
Kidney or Bladder Problem
Yes
No
Bone or Joint Problems
Yes
No
Arthritis
Yes
No
Back or Neck Pain
Yes
No
Joint Replacement(e.g., total hip, pins, or implants)
Yes
No
Fainting Spells, Seizures, or Epilepsy
Yes
No
Stroke(s)
Yes
No
Frequent or Severe Headaches
Yes
No
Thyroid Problems
Yes
No
Persistent Cough or Swollen Glands
Yes
No
Premedications Required by Physician
Yes
No
Cancer/Tumor
Yes
No
Diabetes
Yes
No
Urinate More than 6 Times a Day
Yes
No
Thirsty or Mouth is Dry Much of the Time
Yes
No
Family History of Diabetes
Yes
No
Tuberculosis or Other Respiratory Disease
Yes
No
Do You Drink Alcohol?
Yes
No
Do You Smoke?
Yes
No
Hepatitis, Jaundice, or Liver Trouble
Yes
No
Herpes or Other STD
Yes
No
HIV-Positive/AIDS
Yes
No
Glaucoma
Yes
No
Do You Wear Contact Lenses?
Yes
No
History of Head Injury?
Yes
No
Epilepsy or Other Neurological Disease?
Yes
No
History of Alcohol or Drug Abuse?
Yes
No
Do You Have Any Disease, Condition, or Problem Not Listed Previously That You Feel We Should Know About?
Yes
No
I have answered all the above questions

Medical History

Are you a woman?
Yes
No
Are you taking contraceptives or other hormones?
Yes
No
Are you pregnant?
Yes
No
Are you Nursing
Yes
No
Have you reached menopause?
Yes
No
Are you allergic, or have you reacted adversely, to any of the following?
I have answered all the above questions

Medical History

During the past 12 months, have you taken any of the following?
I have answered all the above questions
SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

Are you apprehensive about dental treatment?
Yes
No
Have you had problems with previous dental treatment?
Yes
No
Do you gag easily?
Yes
No
Do you wear dentures?
Yes
No
Does food catch between your teeth?
Yes
No
Do you have difficulty in chewing your food?
Yes
No
Do you chew on only one side of your mouth?
Yes
No
Do you avoid brushing any part of your mouth because of pain?
Yes
No
Do your gums bleed easily?
Yes
No
Do your gums bleed when you floss?
Yes
No
Do your gums feel swollen or tender?
Yes
No
Have you ever noticed slow-healing sores in or about your mouth?
Yes
No
Are your teeth sensitive?
Yes
No
Do you feel twinges of pain when your teeth come in contact with:
Hot foods or liquids?
Yes
No
Cold food or liquids?
Yes
No
Sours?
Yes
No
Sweets
Yes
No
Do you take fluoride supplements?
Yes
No
Are you dissatisfied with the appearance of your teeth?
Yes
No
Do you prefer to save your teeth?
Yes
No
Do you want complete dental care?
Yes
No

How often do you brush?
How often do you floss?
Does your jaw make noise so that it bothers you or others?
Yes
No
Do you clench or grind your jaws frequently?
Yes
No
Do your jaws ever feel tired?
Yes
No
Does your jaw get stuck so that you can't open freely?
Yes
No
Does it hurt when you chew or open wide to take a bite?
Yes
No
Do you have earaches or pain in front of the ears?
Yes
No
Do you have any jaw symptoms or headaches upon awaking in the morning?
Yes
No
Does jaw pain or discomfort affect your appetite, sleep, daily routine, or other activities?
Yes
No
Do you find jaw pain or discomfort extremely frustrating or depressing?
Yes
No
Do you take medications or pills for pain or discomfort (pain relievers, muscle relaxants, antidepressants)?
Yes
No
Do you have a temporomandibular (jaw) disorder (TMD)?
Yes
No
Do you have pain in the face, cheeks, jaws, joints, throat, or temples?
Yes
No
Are you unable to open your mouth as far as you want?
Yes
No
Are you aware of an uncomfortable bite?
Yes
No
Have you had a blow to the jaw (trauma)?
Yes
No
Are you a habitual gum chewer or pipe smoker?
Yes
No

Our Dental Office Privacy Policy

As dental professionals, Dr.Scarbrough and his staff implemented this health information Privacy Policy and Procedures to protect the interest of our patients and fulfill our legal obligations under the Health Insurance Portability and Accountability Act of 1996(HIPAA), the amended modifications of 2002 and state law that provide greater information are important to us. We may use your health information:

  • To other dental specialist to who you are referred
  • To provide you with appointment reminders
  • To you or anyone you may designate in writing
  • To obtain payment for services we have provided you
  • When required by law

As a patient you have the right to view or transfer your dental records

If you want more information about the privacy practices of this dental office, or if you are concerned that we may have violated your privacy rights, please contact our office.

We support your right to the privacy of your health information.

Contact Officer:
Pamela Scarbrough
870.739.3600
Acknowledgment of Receipt of Notice of Privacy Policy
I have read a copy of this office's Notice of Practices
SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

Policies and Procedures

Please initial after you have read the below information.
Thank you for your cooperation and understanding.

Due to the increasing number of broken appointments, all appointments must be cancelled 24 hours prior to appointment time. If appointments are not cancelled a $50 "no show" fee will be added to patients account.

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

Due to limited size of our operatory, we request that only the patient be in the room during any procedure. This will save you time and let us work more efficiently.

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

All insurance claims are filed by our office for your convenience. If claims are not paid by your insurance within 6 months, it is the patients responsibility to pay the uncovered portion to our office. All other dealings with insurance will be done by the patient.

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

NO cell phones to be used in our operatory. Our time with you is limited.

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

Payment is expected when services are rendered; unless other arrangements are made in advance.

SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )
Thank you for visiting Scarbrough 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:           Date Of Birth:          
Gender:           Home Address:          
City:           State:           Zip:          

Billing Address

Billing Address(if different):       City:           State:           Zip Code:          

How do we contact you?

Home Phone:           Cell Phone:           Work Phone:
Email Address:           Driver's License:           State:          
SS #:           Employer/Occupation:           Business Phone:          

Previous Medical Visit

Name of your Medical Doctor:           Date of Last Visit to Medical Doctor: Name of Previous Dentist: Date of Last Visit to Dentist: Referred to us by:

Spouse Information

Emergency Contact

Spouse Name:
Phone Number:
Emergency Phone #(other than spouse):
Emergency Phone #(other than spouse):
Are You Married? Yes No

Primary Insurance Information

Primary Dental Insurance: Group #: Subscriber's Name: Date of Birth: SS #:
Do You have Primary Insurance? Yes No

Secondary Insurance Information

Secondary Dental Insurance: Group #: Subscriber's Name: Date of Birth: SS #:
Do You have Secondary Insurance? Yes No
Medical History
Do you have, or have you had, any of the following?
Heart Problems
Yes
No
Blood Problems
Yes
No
Allergy Problems
Yes
No
Intestinal Problems
Yes
No
Bone or Joint Problems
Yes
No
Fainting Spells, Seizures, or Epilepsy
Yes
No
Stroke(s)
Yes
No
Frequent or Severe Headaches
Yes
No
Thyroid Problems
Yes
No
Persistent Cough or Swollen Glands
Yes
No
Premedications Required by Physician
Yes
No
Cancer/Tumor
Yes
No
Diabetes
Yes
No
Tuberculosis or Other Respiratory Disease
Yes
No
Do You Drink Alcohol?
Yes
No
Details:
Do You Smoke?
Yes
No
Details:
Hepatitis, Jaundice, or Liver Trouble
Yes
No
Herpes or Other STD
Yes
No
HIV-Positive/AIDS
Yes
No
Glaucoma
Yes
No
Do You Wear Contact Lenses?
Yes
No
History of Head Injury?
Yes
No
Epilepsy or Other Neurological Disease?
Yes
No
History of Alcohol or Drug Abuse?
Yes
No
Do You Have Any Disease, Condition, or Problem Not Listed Previously That You Feel We Should Know About?
Yes
No
Details:
Are you a woman?
Yes
No
Are you allergic, or have you reacted adversely, to any of the following?
Local anesthetics("Novocaine") Penicillin or other antibiotics Sulfa drugs Barbiturates, sedatives, or sleeping pills
Aspirin, Acetaminophen, or Ibuprofen Codeine, Demerol, or other narcotics Reaction to Metals Latex or rubber dam
Others
If Others, Please Specify:
Notes:    
Are you allergic, or have you reacted adversely, to any of the following?
Antibiotics or sulfa drugs Anticoagulants (e.g., Coumadin) High blood pressure medicine Tranquilizers sleeping pills
Insulin, Orinase, or similar drug Aspirin Digitalis or drugs for heart trouble Nitroglycerin
Cortisone (steroids) Natural Remedies Nonprescription drug/supplements Other
If Other, Please Specify:
Notes:    
 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS
Dental History
Are you apprehensive about dental treatment?
Yes
No
Have you had problems with previous dental treatment?
Yes
No
Do you gag easily?
Yes
No
Do you wear dentures?
Yes
No
Does food catch between your teeth?
Yes
No
Do you have difficulty in chewing your food?
Yes
No
Do you chew on only one side of your mouth?
Yes
No
Do you avoid brushing any part of your mouth because of pain?
Yes
No
Do your gums bleed easily?
Yes
No
Do your gums bleed when you floss?
Yes
No
Do your gums feel swollen or tender?
Yes
No
Have you ever noticed slow-healing sores in or about your mouth?
Yes
No
Are your teeth sensitive?
Yes
No
Do you feel twinges of pain when your teeth come in contact with:
Hot foods or liquids?
Yes
No
Cold food or liquids?
Yes
No
Sours?
Yes
No
Sweets?
Yes
No
Do you take fluoride supplements?
Yes
No
Are you dissatisfied with the appearance of your teeth?
Yes
No
Do you prefer to save your teeth?
Yes
No
Do you want complete dental care?
Yes
No
How often do you brush?
How often do you floss?
Does your jaw make noise so that it bothers you or others?
Yes
No
Do you clench or grind your jaws frequently?
Yes
No
Do your jaws ever feel tired?
Yes
No
Does your jaw get stuck so that you can't open freely?
Yes
No
Does it hurt when you chew or open wide to take a bite?
Yes
No
Do you have earaches or pain in front of the ears?
Yes
No
Do you have any jaw symptoms or headaches upon awaking in the morning?
Yes
No
Does jaw pain or discomfort affect your appetite, sleep, daily routine, or other activities?
Yes
No
Do you find jaw pain or discomfort extremely frustrating or depressing?
Yes
No
Do you take medications or pills for pain or discomfort (pain relievers, muscle relaxants, antidepressants)?
Yes
No
Do you have a temporomandibular (jaw) disorder (TMD)?
Yes
No
Do you have pain in the face, cheeks, jaws, joints, throat, or temples?
Yes
No
Are you unable to open your mouth as far as you want?
Yes
No
Are you aware of an uncomfortable bite?
Yes
No
Have you had a blow to the jaw (trauma)?
Yes
No
Are you a habitual gum chewer or pipe smoker?
Yes
No

Our Dental Office Privacy Policy

As dental professionals, Dr.Scarbrough and his staff implemented this health information Privacy Policy and Procedures to protect the interest of our patients and fulfill our legal obligations under the Health Insurance Portability and Accountability Act of 1996(HIPAA), the amended modifications of 2002 and state law that provide greater information are important to us. We may use your health information:

  • To other dental specialist to who you are referred
  • To provide you with appointment reminders
  • To you or anyone you may designate in writing
  • To obtain payment for services we have provided you
  • When required by law

As a patient you have the right to view or transfer your dental records

If you want more information about the privacy practices of this dental office, or if you are concerned that we may have violated your privacy rights, please contact our office.

We support your right to the privacy of your health information.

Contact Officer:
Pamela Scarbrough
870.739.3600
Acknowledgment of Receipt of Notice of Privacy Policy
I have read a copy of this office's Notice of Practices
 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

Policies and Procedures

Please initial after you have read the below information.
Thank you for your cooperation and understanding.

Due to the increasing number of broken appointments, all appointments must be cancelled 24 hours prior to appointment time. If appointments are not cancelled a $50 "no show" fee will be added to patients account.

 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

Due to limited size of our operatory, we request that only the patient be in the room during any procedure. This will save you time and let us work more efficiently.

 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

All insurance claims are filed by our office for your convenience. If claims are not paid by your insurance within 6 months, it is the patients responsibility to pay the uncovered portion to our office. All other dealings with insurance will be done by the patient.

 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

NO cell phones to be used in our operatory. Our time with you is limited.

 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

Payment is expected when services are rendered; unless other arrangements are made in advance.

 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

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