Patient Registration
Patient Information
Patient Status*
How did you hear about our office?*
Do you have insurance ?*
Primary Insurance Information
Relationship to Insured*
Do you have secondary insurance?*
Secondary Insurance Information
Relationship to Insured*
Medical and Dental Health History
Parents Information
Is your child's water fluoridated?*
Does your child take fluoride supplements?*
Does your child:
Suck thumb/finger ?*
Suck/bite lips?*
Bite/chew nails?*
Chew hard objects(pencils, etc.)?*
Grind teeth?*
Clench jaws?*
Has your child had difficulty with previous dental visits?*
Previous Hospitalizations / Surgeries / Serious Illness?
Is your child taking medications?*
Has your child ever taken FenPhen or Redux?*
Does your child have a history of:
- Allergies
- Sensitivities
- Adverse reactions to any drugs or medications (penicillin, novacain, etc)*
Does your child have a history of allergies to any other substances (latex, environment, etc.)?*
Has your child ever had any one of the following:*
Persistent cough or throat clearing not associated with a known illness(lasting more than 3 weeks)*
Abnormal bleeding*
Acid Reflux*
Stomach, Liver or Kidney problems*
Handicaps/ Disabilities*
Rheumatic Fever*
Congenital Heart Defect*
Heart Murmur*
Convulsions / Epilepsy*
Medical Health History
Are you under a physician's care now?*
Have you been hospitalized or had a major operation?*
Have you ever had a head, neck or jaw injury?*
Are you taking prescriptions or over the counter medications?*
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?*
Do you use controlled substances?*
Do you currently take blood thinners?*
Women: Are you...
Are you allergic to any of the following?
Do you have any other allergies not listed above?*
Do you snore loudly?*
Do you often feel tired, fatigued or sleepy during the day?*
Has anyone noticed that you stop breathing while you are sleeping?*
Do you have or have you had any of the following?*
Acid Reflux/GERD*
AIDS/HIV Positive*
Artificial Heart Valve*
Artificial Joint*
Chest Pain*
Drug Addiction*
Easily Winded*
Fainting Spells/Dizziness*
Frequent Headaches*
Hay Fever*
Heart Attack/Disease*
Heart Murmur*
Heart Pacemaker*
High Blood Pressure*
High Cholesterol*
Kidney Problems*
Low Blood Pressure*
Mitral Valve Prolapse*
Radiation treatment to head or neck*
Recent Weight Loss*
Rheumatic Fever*
Sickle Cell Disease*
Sinus Trouble*
Sleep Apnea*
Stomach/Intestinal Disease*
Thyroid Disease*
Venereal Disease*
Have you ever had any serious illness not listed above?*
Dental Health History
Have you ever experienced any of the following problems in your jaw?
Difficulty in opening or closing?*
Pain (joint, ear, side of face)*
Difficulty in chewing?*
Do your gums bleed while brushing or flossing?*
Are your teeth sensitive to hot or cold liquids/foods?*
Are your teeth sensitive to sweet or sour food/liquids?*
Do you currently have pain in your teeth?*
Do you have any sores or lumps in or near your mouth?*
Do you have frequent headaches?*
Do you clench or grind your teeth?*
Do you bite your lips or cheeks frequently?*
Have you had difficult extractions in the past?*
Have you ever had any prolonged bleeding following an extraction?*
Have you ever had orthodontic treatment (braces to straighten your teeth)?*
Have you received oral hygiene instructions regarding care of your teeth and gums?*
Are you interested in learning more about how to enhance your smile?*
Authorization and Release
Eric J. Etheridge, D.D.S.
Financial Policy and Consent to Treatment and Authorization and Release

Thank you for choosing Dr. Etheridge as your dentist. His concern is that you receive the finest, most appropriate dental care you need, when you need it. Payment for services is expected at the time services are rendered. The office accepts cash, checks, Visa, MasterCard and Discover. Care Credit may also be available for those patients who qualify. As a service to our patients, we file primary insurance claims. The patient is responsible for providing the office with current insurance coverage information, deductible and annual benefit maximum amounts, the name of your employer, and any change in coverage status. Your insurance policy is a contract between the insurance carrier and you. For our patients with dental insurance, we expect your estimated co-payment amount at the time services are rendered. The balance of the fee for services rendered is your responsibility regardless of whether your insurance company pays or not. If your insurance company has not paid your account in full within 90 days, the balance of your account will automatically be billed to you. We will be glad to provide the necessary information to you so you can pursue payment from your insurance company. Please be aware that some dental services provided may be “non-covered” services under your insurance policy and that, in some instances, coverage provided by insurance may be less than anticipated. Dr. Etheridge’s responsibility is to your oral health, and the trust you have in him will not be manipulated by an insurance carrier. Please notify us 24 hours in advance of any change that must be made to a scheduled dental appointment. There will be a $50 per hour charge for a failed appointment. To the best of my knowledge, the questions on the medical health history have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the dental office of any changes in my medical status. I also authorize the dental staff to perform the necessary dental services needed. I also authorize Dr. Eric Etheridge to release any information including the diagnosis and the records of treatment or examination rendered during the period of such care to third party payers and/or other health practitioners. I authorize and request my insurance company to pay directly to Dr. Eric Etheridge group insurance benefits otherwise payable to me. I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.
Signature of Acknowledgement
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You have submitted the Form Succesfully. Thank you for choosing Etheridge Family and Cosmetic Dentistry.

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