New Patients
1. Your new patient registration forms need to
be completed prior to your dental
appointment. The forms can be downloaded
from our web site at
www.rexpayne.com if it was not mailed to
you.
2. Please provide us with your dental insurance
information prior to your appointment.
3. Bring your dental insurance card and present
it to the receptionist upon arrival. If
you do not have a dental insurance card, please let us know.
4. Important – please bring any current
dental x-rays to assist us with your dental treatment. You will need to pick up your x-rays or have
them mailed to us from your previous Dentist.
5. Please call our office (972) 221-9136 prior
to your appointment to verify we have received all necessary information and
your dental insurance has been confirmed.
6. If you will be more than 10 minutes late for
your appointment, please call our office to verify that your appointment can
still be accommodated.
7. Office services, Co-Pays or Deductibles are
payable at the time of services. Payment
can be made by Visa, MasterCard, Discover, American Express, cash or check.
We are looking forward to
meeting you and helping you with your dental needs. Thank You.
Rex Alan Payne, D.D.S.
Rex Alan
Payne, D.D.S.
PATIENT
REGISTRATION
Patient Name: ___________________________________________Date:_________
First MI Last (Preferred Name)
Address:
_____________________________________________________________
Street Apartment
number
_____________________________________________________________________
City State Zip
Code
Birth Date_____________ Driver
License #__________________SS#_____________
Hm. Ph._______________ Wk. ____________________X
_______Cell#__________
Employer:______________________________ Occupation______________________
Circle one: Male /
Female Circle one: Single
/ Married /
Divorced / Child
Spouse
or Parent’s Information
Parent
(or) Spouse’s Name ________________________________________________
Parent
(or) Spouse’s Employer _______________Occupation ____________________
Parent
(or)Spouse’s work #______________________________cell
#______________
Family
member not living with you Name ______________________Ph#:___________
Insurance Information
Name of Insured: ______________________________________________________________________
Last First
MI
Insured's Birth Date: ___________ SS / ID #: _______________________ Group #: _________________
Insured's Employer Name: _______________________________________________________________
Patient's relationship to insured: 
Self Spouse
Child Other ________________________
Name of Insurance Company: ____________________________________________________________
Insurance
Who referred you to
our office? Name ______________________________________
Phone Book_______________(or)
Internet ___________________________________
Reason for
our visit here today _____________________________________________
Have your ever had any of the
following? Please check those that
apply:
Allergic to:__________________________________________________________________________
Codeine/Vicodin
Allergy
Hepatitis A
AIDS
Penicillin Allergy
Hepatitis B
Venereal Disease
Latex Allergies
Hepatitis C
Tuberculosis
Blood Disease
Liver Disease
PRE-MED
Excessive Bleeding
High Blood Pressure
Heart Murmur
Cancer/Tumors
Kidney Disease
Mitral Valve Prolapse
Radiation Treatment
Herpes /Mouth
Artificial Joints
Diabetes
Pregnant
Rheumatic Fever
Fainting Due
date: __________
Pacemaker
Head Injuries
Asthma
Heart Attack
Mental Disorders
Respiratory Problems
Heart Surgery
Dizziness Sinus Problems
Heart Disease
Stomach Problems
Other
problems not listed ________________________________________________________________
____________________________________________________________________________________
· Have you ever had any complications
following dental treatment? Yes No
If yes, please explain: ________________________________________________________________
· Are you now under the care of a
physician? Yes No
If yes, please explain: ________________________________________________________________
· Name of Physician:
· I am currently taking the following medications:
___________________________________________________________________________________
Are
you allergic to any medication or other products not listed above, if so please
list : _______________
____________________________________________________________________________________
Consent for Services
As a condition of your treatment by this office, financial arrangements must be made in advance. All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in full at the time services are performed. As a courtesy, this office will help file the patients’ insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient's account.
In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable fees accrue hereunder.
I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form. I have read the above conditions of treatment and payment and agree to their content.
Patient is responsible for an unpaid balance not paid
by your insurance.
All deductibles
and co-pays are due at time of appointment. If unable to keep Appointment Kindly Give us
a 24 Hours Notice. Penalties May Apply.
To the best of my knowledge, all of the
preceding answers and information provided are true and correct. If I ever have any change in my health, I
will inform the doctors at the next appointment without fail.
_________________________________________________________________
Date:
Signature of patient, parent or guardian
Doctors / Staff
Notes
Date__________ Date__________ Date__________ Date___________ Date___________ Date