Fill Out Form Patient Registration

NEW PATIENTS

Schedule an Appointment (949) 569-5253

New Patient Registration Fields marked with * are required

First Name *

Last Name *

Preferred Name

Gender * Male Female

Date Of Birth *

Driver's License Number

SSN

Address *

Address (optional)

City *

State *

Zip *

Primary Phone *

Work Phone

Emergency Phone

Employer

Occupation

Employment Status

Previous Dentist

Referred By

Responsible Party (if someone other than patient) Fields marked with * are required

Relation To Patient

First Name

Last Name

Preferred Name

Gender Male Female

Date Of Birth

Driver's License Number

SSN

Address

Address (optional)

City

State

Zip

Primary Phone

Work Phone

Emergency Phone

Employer

Occupation

Employment Status

Referred By

Insurance Information Fields marked with * are required

Insurance Company Name

SSN or ID Number

Group Number

First Name

Last Name

Date of Birth

Gender Male Female

Address

Address (optional)

City

State

Zip

Employer

Occupation

Employment Status

Secondary Insurance Information Fields marked with * are required

Insurance Company Name

SSN or ID Number

Group Number

First Name

Last Name

Date of Birth

Gender Male Female

Address

Address (optional)

City

State

Zip

Employer

Occupation

Employment Status

Health History Fields marked with * are required

Are you currently being treated by a physician? * Yes No

If Yes:

Have you ever been hospitalized or had a major operation? * Yes No

If Yes:

Have you ever had a serious head or neck injury? * Yes No

If Yes:

Are you taking any medications, pills, or drugs? * Yes No

If Yes:

Do you take, or have you taken, Phen-Fen or Redux? * Yes No

If Yes:

Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? * Yes No

If Yes:

Are you on a special diet? * Yes No

If Yes:

Do you use tobacco? * Yes No

Do you use controlled substances? * Yes No

If Yes:

Women: Are you pregnant / Trying to get pregnant? * Yes No

Nursing? * Yes No

Taking oral contraceptives? * Yes No

Are you allergic to any of the following? Fields marked with * are required

Aspirin * Yes No

Penicillin * Yes No

Codeine * Yes No

Acrylic * Yes No

Metal * Yes No

Latex * Yes No

Sulfa Drugs * Yes No

Local Anesthetics * Yes No

Other? * Yes No

If Yes:

Do you have, or have you had, any of the following? Fields marked with * are required

AIDS/HIV Positive

Alzheimer's Disease

Anaphylaxis

Anemia

Angina

Arthritis/Gout

Artificial Heart Valve

Artificial Joint

Asthma

Blood Disease

Blood Transfusion

Breathing Problems

Bruise Easily

Cancer

Chemotherapy

Chest Pains

Cold Sores / Fever Blisters

Congenital Heart Disorder

Convulsions

Yellow Jaundice

Cortisone Medicine

Diabetes

Drug Addiction

Easily Winded

Emphysema

Epilepsy or Seizures

Excessive Bleeding

Excessive Thirst

Fainting Spells / Dizziness

Frequent Cough

Frequent Diarrhea

Frequent Headaches

Genital Herpes

Glaucoma

HayFever

Heart Attack / Failure

Heart Murmur

Heart Pacemaker

Heart Trouble / Disease

Sleep Apnea

Hemophilia

Hepatitis A

Hepatitis B or C

Herpes

High Blood Pressure

High Cholesterol

Hives or Rash

Hypoglycemia

Irregular Heartbeat

Kidney Problems

Leukemia

Liver Disease

Low Blood Pressure

Lung Disease

Mitral Valve Prolapse

Osteoporosis

Pain In Jaw Joints

Parathyroid Disease

Psychiatric Care

Snoring

Radiation Treatments

Recent Weight Loss

Renal Dialysis

Rheumatic Fever

Rheumatism

Scarlet Fever

Shingles

Sickle Cell Disease

Sinus Trouble

Spina Bifida

Stomach / Intestinal Disease

Stroke

Swelling Of Limbs

Thyroid Disease

Tonsillitis

Tuberculosis

Tumors or Growths

Ulcers

Venereal Disease

Have you ever had any serious illnes not listed? * Yes No

If Yes:

Comments

Terms And Conditions Fields marked with * are required

Terms * I understand that the information that I have given today is correct to the best of my knowledge and that providing incorrect information can be dangerous to my (or patient's) health. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.

Release Authorization Fields marked with * are required

I authorize Jeff Kindseth DDS and office staff to release or request my medical and/or billing information to the following individuals:

HIPAA and Privacy Practices Consent Fields marked with * are required

HIPAA Consent * I give this practice/ clinic my consent to use or disclose my protected health information to carry out my treatment, to obtain payment from insurance companies, and for health care operations like quality reviews.
I give this practice consent to leave messages with household members and answering machines when necessary.
I have been informed that I may review the practice's "Notice of Privacy Practices" (for a more complete description of uses and disclosures) before signing this consent.
I understand that this practice has the right to change their Privacy Practices and that I may obtain any revised notices at the practice.
I understand that I have the right to request a restriction of how my protected health information is used. However, I also understand that the practice is not required to agree to the request. If the practice agrees to my requested restriction, they must follow restriction(s).
I also understand that I may revoke this consent at any time by making a request in writing, except for information already used or disclosed.

Signature Fields marked with * are required

Date: 10/29/2024

Jeff Kindseth, DDS

HOURS OF OPERATION

SERVICES

HELPFUL LINKS