Registration Form

Dentist Eden Prairie

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WELCOME

ANDERSON LAKE DENTAL REGISTRATION FORM

COVID-19 Disclosure

This patient disclosure form seeks information from you that we must consider before making treatment decisions in the circumstance of the COVID‐19 virus.

A weak or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD, cancer treatment, radiation, chemotherapy, and any prior or current disease or medical condition), can put you at a greater risk for contracting COVID-19. Please disclose to us any condition that compromises your immune system and understand that we may ask you to consider rescheduling treatment after discussing any such conditions with us.

Have you or anyone you've been in contact with in the last 21 days experienced any of the following:

Fever Yes No

Cough Yes No

Shortness of breath or difficulty in breathing Yes No

Loss of taste or smell Yes No

Any flu like symptoms Yes No

Have you or anyone you have been in contact with traveled by air or cruise ship within the past 14 days? Yes No

Have you been in contact with anyone with a positive covid-19 case? Yes No

Patient Information

Date

Name

I Prefer to be called:

Address

City

State

Zip

Phone

Work Phone

Cell Phone

Email Address

Date of Birth

Social Security Number

Check Appropriate Box Minor Single Married Widowed Separated Divorced

Spouse or Parent’s Name:

Employer

Work Phone

How did you hear about our office?

Person to contact in case of emergency

Phone

Responsible Party

Relationship to Patient: Self Spouse Parent Other

Name

Relationship to Patient:

Address:

City

State

Zip

Phone

Employer

Work Phone

SSN#

Step 1

CONSENT TO USE PHOTOGRAPHS

I, (patient or Parents name) herby authorize Anderson Lake Dental to take photographs, and/or videos of my face, jaw, teeth, before, during and after treatment.

I consent for the photograph and/or videos to be used for the following:

  • Dental Educations including lectures, seminars, professional publications such as journal or books
  • Marketing material, including websites, Facebook, printed material and patient education

I further understand that if the photograph and/or videos are used, my name or any other identifying information will be kept confidential

Check here if you do not want your full face shot used for any of the above purposes

Check here if you do not want us to use any photos/videos for any of the above purposes

Patient Name (Print Please):

Patient or Guardian Signature

Date

ANDERSON LAKE DENTAL HEALTH HISTORY FORM

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

Name

Date

If you are completing this form for another person, what is your relationship to that person?

Name

Relationship

Do you have any of the following diseases or problems: (Check DK if you Don’t Know the answer to the question)

Active Tuberculosis Yes No Don't Know

Persistent cough greater than a 3 week duration Yes No Don't Know

Cough that produces blood Yes No Don't Know

Been exposed to anyone with tuberculosis Yes No Don't Know

DENTAL INFORMATION

Do your gums bleed when you brush or floss Yes No Don't Know

Are your teeth sensitive to cold, hot ,pressure Yes No Don't Know

Does food or floss catch between your teeth Yes No Don't Know

Is your mouth dry Yes No Don't Know

Have you had any periodontal (gum) treatments Yes No Don't Know

Have you ever had orthodontic (braces) treatment Yes No Don't Know

Have you had any problems associated with previous dental treatment. Yes No Don't Know

Do you drink bottle or filtered water Yes No Don't Know

Are you currently experiencing pain/discomfort Yes No Don't Know

What is the reason for your dental visit today?

Do you have earaches or neck pains Yes No Don't Know

Do you have any discomfort in the jaw Yes No Don't Know

Do you brux or grind your teeth Yes No Don't Know

Do you have sores or ulcers in your mouth Yes No Don't Know

Do you wear dentures or partials Yes No Don't Know

Do you participate in active activities Yes No Don't Know

Have you had a serious head or mouth injury Yes No Don't Know

Date of your last dental exam

Date of last dental x-rays

How do you feel about your smile?

MEDICAL INFORMATION

Are you now under the care of a physician Yes No Don't Know

Physician Name

Phone

Are you in good health Yes No Don't Know

Has there been any change in your general health within the past year? Yes No Don't Know

If yes, what condition is being treated

Date of last physical exam

Have you had a serious illness, operation or been hospitalized in the past 5 years Yes No Don't Know

If yes, what was the illness or problem

Are you taking or have you recently taken any prescription or over the counter medicines Yes No Don't Know

If so, please list all, including vitamins, natural or herbal preparations and/or diet supplements

Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement? Yes No Don't Know

Scheduled to begin treatment with the intravenous bisphosphonates (Aredia or Zometa) for bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease, multiple myeloma, metastatic cancer Yes No Don't Know

Date treatment began

Do you use tobacco (smoking, snuff, chew, bidis) Yes No Don't Know

WOMEN ONLY, are you:

Pregnant? Yes No Don't Know

Number of weeks:

Taking birth control pills or hormonal replacement Yes No Don't Know

Nursing Yes No Don't Know

ALLERGIES

Are you allergic to or have you had a Reaction to:

Local anesthetics Yes No Don't Know

Aspirin Yes No Don't Know

Penicillin or other antibiotics Yes No Don't Know

Barbiturates, sedatives, or sleeping pills Yes No Don't Know

Sulfa drugs Yes No Don't Know

Codeine or other narcotics Yes No Don't Know

Metals Yes No Don't Know

Latex (rubber) Yes No Don't Know

Iodine Yes No Don't Know

Hay fever/seasonal Yes No Don't Know

Animals Yes No Don't Know

Food Yes No Don't Know

Other

Artificial (prosthetic) heart valve Yes No Don't Know

Damaged valves in transplanted heart Yes No Don't Know

Previous infective endocarditis Yes No Don't Know

Congenital heart disease Yes No Don't Know

COPD Yes No Don't Know

Low blood pressure Yes No Don't Know

Anemia Yes No Don't Know

Rheumatoid arthritis Yes No Don't Know

Chronic pain Yes No Don't Know

Sleep disorder Yes No Don't Know

Kidney problems Yes No Don't Know

Sexually transmitted disease Yes No Don't Know

Angina Yes No Don't Know

Damaged heart valves Yes No Don't Know

Mitral valve prolapsed Yes No Don't Know

Rheumatic heart disease Yes No Don't Know

Blood transfusion Yes No Don't Know

Systemic lupus Yes No Don't Know

Gastrointestinal disease Yes No Don't Know

Thyroid problems Yes No Don't Know

Severe headaches/migraines Yes No Don't Know

Heart murmur Yes No Don't Know

Asthma Yes No Don't Know

Stroke Yes No Don't Know

Neurological disorders Yes No Don't Know

Recurrent infections Yes No Don't Know

Autism Yes No Don't Know

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

Signature of Patient/Legal Guardian:

Date

Recorded By:

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

SECTION A: PATIENT GIVING CONSENT

Name:

Address:

Telephone:

Email:

Social Security #:

SECTION B: TO THE PATIENT—PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. We encourage you to read it carefully and completely before signing this Consent,

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting: Joe Bishop at 952-942-0823, Fax: 952-224-2986

Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on the Consent before we received your revocation, and that we may decline to treat you or continue treating you if you revoke this Consent.

I have had full opportunity to read and consider the contents of the Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations.

If this Consent is signed by a personal representative on behalf of the patient, please complete the following:

Personal Representative’s Name:

Relationship to Patient:

YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT

Written Financial Policy

Thank you for choosing Anderson Lake Dental. Our primary mission is to deliver the best and most comprehensive dental care available. An important part of the mission is making the cost of optimal care as easy and manageable for our patients as possible by offering several payment options.

Payment Options:

You can choose from:

  • Cash, Check, Visa, MasterCard, American Express or Discover Card
    We offer a 5% courtesy accounting adjustment to patients who pay for their treatment with no insurance discount prior to completion of care.
  • Convenient Monthly Payment Options¹ from CareCredit Healthcare Credit Card
  • Anderson Lake Dental Discount Plan (Ask front desk for details)

Please note:

Anderson Lake Dental requires payment prior to the completion of your treatment. If you choose to discontinue care before treatment is complete, you will receive a refund less the cost of care received.

For plans requiring multiple appointments, alternative payment arrangements may be provided.

For patients with dental insurance we are happy to work with your carrier to maximize your benefit and directly bill them for reimbursement for your treatment.²

Anderson Lake Dental charges $30 for returned checks. Anderson Lake Dental charges a missed appointment fee of $45 for all appointments that are missed or canceled without proper notice.

If you have any questions, please do not hesitate to ask. We are here to help you get the dentistry you want or need.

Patient, Parent or Guardian Signature

Date

Patient Name (Please Print)

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