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Patient Registration

Patient Credentials

Patient is:
Preferred Name:
Responsible Party (if someone other than the patient)
holder information radio
Patient Information
Marital Status:
Employment Status:
Student Status

Primary Insurance Information

Name of Insured:
Relationship to Insured:
Employer Address:
Home Address

Secondary Insurance Information

Name of Insured:
Relationship to Insured:
Employer Address:
Home Address:

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Please list any health problems you may have or medications you are taking.

Are you under a physician’s care now?
Have you ever been hospitalized or had a major operation?
Have you ever had a serious head or neck injury?
Are you taking any medications, pills, or drugs?
Do you take, or have you taken, Phen-Fen or Redux?
Have you ever taken Fosamax, Boniva, Actonel, or any other medications containing bisphosphonates?
Are you on a special diet?
Do you use tobacco or a vape?
Do you use controlled substances?

Please answer the below if you are a Woman:

pregant,nursing etc
Are you allergic to any of the following?

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

AIDS/HIV Positive:
Alzheimer’s Disease
Artificial Heart Valve
Artificial Joint
Blood Disease
Blood Transfusion
Breathing Problems
Bruise Easily
Chest Pains
Cold Sores / Fever Blisters
Congenital Heart Disorder
Cortisone Medicine
Drug Addiction
Easily Winded
Epilepsy or Seizures
Excessive Bleeding
Excessive Thirst
Fainting Spells / Dizziness
Frequent Cough
Frequent Diarrhea
Frequent Headaches
Genital Herpes
Hay Fever
Heart Attack / Failure
Heart Murmur
Heart Pacemaker
Heart Trouble / Disease
Hepatitis A
Hepatitis B or C
High Blood Pressure
High Cholesterol
Hives or Rash
Irregular Heartbeat
Kidney Problems
Liver Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse
Pain in Jaw Joints
Parathyroid Disease
Psychiatric Care
Radiation Treatments
Recent Weight Loss
Renal Dialysis
Rheumatic Fever
Scarlet Fever
Sickle Cell Disease
Sinus Trouble
Spina Bifida
Stomach / Intestinal Disease
Swelling of Limbs
Thyroid Disease
Tumors or Growths
Venereal Disease
Yellow Jaundice
Have you ever had any serious illness not listed above?
Signature of Patient, Parent, or Guardian:
Your Child(ren)’s Names:
Your Child(ren)’s Names:
Your Child(ren)’s Names:
Your Child(ren)’s Names:


1. As the parent/legal guardian of the child(ren) listed above, I authorize Owens Family & Cosmetic Dentistry to perform all recommended treatment, including but not limited to:

  • a. All recommended treatment;
  • b. Radiographs, study models, photos, and other diagnostic aids or materials (collectively, “Diagnostic Material”) as needed to make a thorough diagnosis;
  • c. The use of anesthetics, nitrous oxide, sedatives, and other medication, as needed, and am fully aware that using anesthetic agents involves certain risks, including but not limited to redness and swelling of tissues, pain, itching, vomiting, dizziness, miscarriage, cardiac arrest, drowsiness, and/or lack of coordination.


2. I am responsible for payment for all services rendered. Should my account become delinquent, I will be responsible for all additional collection costs, including reasonable attorney fees.

Maintaining Appointments

3. A $50 missed appointment fee could be charged to my account for missed appointments or last-minute cancellations by me. I am aware that a 24-hour notice of cancellation is required.


4. I authorize the practice to submit claims for payment for services rendered or pre-authorizations necessary to my insurance company, on my behalf and in my name listed as “signature on file,” and assign to the practice the insurance benefits providing assignment is accepted. I am responsible for payment regardless of coverage provided.

5. I am responsible for providing any insurance changes, should they occur, prior to treatment.

HIPAA Acknowledgement

6. I authorize the practice to release to staff, hospitals, health care services plans, insurance companies, self-insurers or their representatives, specialty dentists involved in my care, any and all information, records, and other diagnostic material about my medical history, services rendered, or recommended treatment.

7. I acknowledge receipt of the Notice of Privacy Practices and authorize the practice to use and disclose my protected health information for any clinical financial, and insurance purposes.

8. I authorize ​sharing​ my protected health information with the following individuals who may be involved in my care and I understand I am responsible to notify the practice of any changes:

9. I authorize the following means of communication:
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