BEAUFORT CENTER FOR DENTISTRY
1264 Ribaut Road, Ste. 401, Beaufort, SC 29902
Phone: (843) 524-7950 Fax: (843) 525-1151
Thank you for choosing Beaufort Center for Dentistry! We strive to provide you with the best dental care. To help us meet your needs,
please fill out this form completely in ink. Your answers are for our records only and will be kept strictly confidential. If you have any
questions or need assistance, please do not hesitate to ask a team member!
New Patient Registration Form
Prefix:____ First Name:________________ Middle Name:____________ Last Name______________ Suffix:___
Preferred Name:__________________ Date of Birth: ________________ SSN:__________________________
Driver’s License Number: _____________________________ Sex: ☐ Male ☐ Female
Marital Status: ☐ Single ☐ Married ☐ Partnership ☐ Separated ☐ Divorced ☐ Widowed
Mailing Address: ____________________________________________________________________________
City________________________________ State __________ Zip_____________
Home Phone: ________________________ Mobile Phone: ________________________
Employer: __________________________________ Occupation: ____________________________________
Work Phone: ________________________
Email Address: ___________________________________________ ☐ Consent for Digital Communications
Preferred Contact Method for Appointment Confirmation: ☐ Home Phone ☐ Work Phone ☐ Cell Phone ☐ Text ☐ Email
How did you learn about our practice? ☐ Google ☐ Facebook ☐ Yelp ☐ Mailer ☐ Word of Mouth/Friend
If you were referred by a friend, whom may we thank? ______________________________________________
Responsible Party:
Are you the Responsible Party? ☐ Yes ☐ No *
If no
,
please fill out the information below.
First Name: __________________ Middle Name: ___________________ Last Name: ____________________
Preferred Name:__________________ Date of Birth: ________________ SSN:__________________________
Mailing Address: ____________________________________________________________________________
City________________________________ State __________ Zip_____________
Home Phone: ________________________ Cell Phone: ________________________
Email Address: ___________________________________________
Relationship to patient:_______________________________________________________________________
Insurance Information:
Name of Insured: ___________________________________________________________________________
Name of Insurance Carrier: _________________________________ Member ID#:_______________________
Relationship to Insured: ___________________________ Group#:___________________________
Insured SSN: __________________________ Insured Date of Birth: ________________
Insured Employer: _________________________________________________________
Do you have secondary coverage? *
If yes, please fill out the information below.
Secondary Insurance Information:
Name of Insured: ___________________________________________________________________________
Name of Insurance Carrier: _________________________________ Member ID#:_______________________
Relationship to Insured: ___________________________ Group#:___________________________
Insured SSN: __________________________ Insured Date of Birth: ________________
Employer: ________________________________________________________
BEAUFORT CENTER FOR DENTISTRY
1264 Ribaut Road, Ste. 401, Beaufort, SC 29902
Phone: (843) 524-7950 Fax: (843) 525-1151
Although dental personnel primarily treat the area in and around your mouth, your oral health and overall health are connected. Health
problems that you may have, or medication that you may be taking, could have an impact on our approach to your dental treatment.
Thank you for answering the following questions as completely and accurately as possible.
Medical History
Prefix:____ First Name:_______________ Middle Name:____________ Last Name______________ Suffix: ___
Emergency Contact Name: __________________________________Phone:____________________________
Preferred Pharmacy:______________________________ Pharmacy Number: ___________________________
Women: Are you ☐ Pregnant or Trying to get pregnant? ☐ Nursing? ☐ Taking oral contraceptives?
Are you allergic to any of the following? ☐ Aspirin ☐ Penicillin ☐ Codeine ☐ Sulfa ☐ Acrylic ☐ Metal ☐ Latex
☐ Oxycodone ☐ Local Anesthetics ☐ Other (Please specify)_________________________________________
Do you have, or have you ever had, any of the following?
☐ AIDS/HIV Positive
☐ Chest Pains
☐ Frequent Headaches
☐ Irregular Heartbeat
☐ Scarlet Fever
☐ Alzheimer’s Disease
☐ Cold Sores/Fever Blisters
☐ Genital Herpes
☐ Kidney Problems
☐ Shingles
☐ Anaphylaxis
☐ Congenital Heart Disorder
☐ Glaucoma
☐ Leukemia
☐ Sickle Cell Disease
☐ Anemia
☐ Convulsions
☐ Hay Fever
☐ Liver Disease
☐ Sinus Trouble
☐ Angina
☐ Cortisone Medicine
☐ Heart Attack/Failure
☐ Low Blood Pressure
☐ Spina Bifida
☐ Arthritis/Gout
☐ Diabetes
☐ Heart Murmur*
☐ Lung Disease
☐ Intestinal Disease
☐ Artificial Heart Valve*
☐ Drug Addiction
☐ Heart Pace Maker*
☐ Mitral Valve Prolapse*
☐ Stroke
☐ Artificial Joint*
Are you under a physician’s care now?
☐ Yes
If yes, please include:
Physician’s Name: ____________________________________
Physician’s Phone Number:_____________________________
Date of Last Physical:__________________________________
Have you ever been hospitalized or had a major operation?
☐ Yes
If yes, please explain:____________________________________________________
Have you ever had a serious head or neck injury?
If yes, please explain:____________________________________________________
☐ Yes
Are you taking any medication, pills, or prescription drugs?
If yes, please include:____________________________________________________
Frequency:_______________________________________________________
☐ Yes
Have you ever reacted adversely to any medications or injections?
☐ Yes
Are you on a special diet?
☐ Yes
Do you use tobacco?
If yes, ☐ smoking ☐ smokeless
☐ Yes
Do you use controlled substances?
☐ Yes
☐ Easily Winded
☐ Heart Trouble/Disease
☐ Pain in Jaw Joints
☐ Swelling of Limbs
☐ Asthma
☐ Emphysema
☐ Hemophilia
☐ Parathyroid Disease
☐ Thyroid Disease
☐ Blood Disease
☐ Epilepsy or Seizures
☐ Hepatitis A
☐ Psychiatric Care
☐ Tonsillitis
☐ Blood Transfusion
☐ Excessive Bleeding
☐ Hepatitis B or C
☐ Radiation Treatments
☐ Tuberculosis
☐ Breathing Problems
☐ Excessive Thirst
☐ Herpes
☐ Recent Weight Loss
☐ Tumors or Growths
☐ Bruise Easily
☐ Fainting Spells/Dizziness
☐ High Blood Pressure
☐ Renal Dialysis
☐ Ulcers
☐ Cancer
☐ Frequent Cough
☐ Hives or Rash
☐ Rheumatic Fever*
☐ Venereal Disease
☐ Chemotherapy
☐ Frequent Diarrhea
☐ Hypoglycemia
☐ Rheumatism
☐ Yellow Jaundice
Dental History
Please check any of the following that apply to you.
Are you interested in having whiter teeth?
☐ Yes ☐ No ☐ I’d like to learn more!
☐ Sensitivity (hot, cold, sweets, pressure)
☐ Tooth pain or discomfort when chewing
If you could improve/enhance your smile,
☐ Headaches, earaches, neck pain
what would you be most interested in?
☐ Grinding or clenching teeth
☐ Make my smile brighter
☐ Bleeding, swollen or irritated gums
☐ Straighten my teeth
☐ Loose, chipped or shifting teeth
☐ Close spaces/gaps in my teeth
☐ Teeth or fillings breaking
☐ Replace old fillings with “tooth colored” fillings
☐ Bad breath or bad taste in your mouth
☐ Repair chipped teeth
☐ Replace missing teeth
☐ I would like a total smile makeover!
__________________________________________________________________________________________
_________________________________________________________________________________________
To the best of my knowledge, the questions answered on this form are complete and correct. I understand that it is
my responsibility to inform the dental office of any changes in my medical status, or my minor’s medical status. I
understand that providing inaccurate or misleading information could be dangerous to my health.
_______________________________________________ ___________________________________
Patient or Guardian Printed Name Date
_______________________________________________ ___________________________________
Patient or Guardian Signature Relationship to Patient
BEAUFORT CENTER FOR DENTISTRY
1264 Ribaut Road, Ste. 401, Beaufort, SC 29902
Phone: (843) 524-7950 Fax: (843) 525-1151
At Beaufort Center for Dentistry, we provide each patient with the best possible dental care. We understand that everyone’s financial
situation is different. For this reason, we have worked hard to provide a variety of payment options to help you receive the quality care
needed to enjoy a healthy and confident smile.
Financial Policy
PAYMENT IN FULL
Full payment is required at the time of service from all patients that do not have insurance coverage.
DENTAL INSURANCE
We are happy to file the forms necessary to see that you receive the full benefits of your coverage. We cannot
guarantee any estimated coverage. By signing this form, you understand and acknowledge the following as it relates
to your insurance:
• I authorize my insurance company to pay to the dentist or dental group all insurance benefits otherwise
payable to me for services rendered. I authorize the use of this signature on all insurance submissions.
• I authorize the dentist to release all information necessary to secure payment of benefits. I understand that I
am financially responsible for all charges whether paid by insurance. Payment and/or insurance copays are
due at the time of treatment unless prior arrangement have been made.
Because the insurance policy is an agreement between you and the insurance company, we ask that patients be
directly responsible for all charges. If for any reason your insurance company has not paid their portion within 60
days from the start of treatment, you are responsible for payment at that time.
PAYMENT OPTIONS
• CASH OR CHECK: Checks returned for insufficient funds will be subject to a $35.00 service fee to cover
bank fees incurred as a result.
• CREDIT CARDS: For your convenience, we accept payment by all major credit cards.
• PAYMENT PLANS: To make our services accessible to as many patients as possible, we accept third-party
payment plans through CareCredit. These plans are like a credit card that is just for health and dental
expenses, and patients can divide the cost of their care into equal monthly payments and pay very little to no
interest.
PAST DUE BALANCES
A past due balance is any amount owed from a prior visit where insurance is not pending, or an insurance payment
has not been received within 60 days. Any delinquent accounts are required to be paid in full before incurring any
new charges. All future charges will need to be paid at the time services are rendered. Severely delinquent accounts
will be assigned to a collection agency and a charge of 35% of the outstanding balance will be assessed to your
account to cover the collection fees.
You have the right to a paper copy of this notice. You may ask us to give you a paper copy of the Notice at any
time (even if you have agreed to receive the Notice electronically).
_______________________________________________ ___________________________________
Patient or Guardian Printed Name Date
_______________________________________________ ___________________________________
Patient or Guardian Signature Relationship to Patient
BEAUFORT CENTER FOR DENTISTRY
1264 Ribaut Road, Ste. 401, Beaufort, SC 29902
Phone: (843) 524-7950 Fax: (843) 525-1151
Notice of Privacy Practices Acknowledgement
You may refuse to sign this.
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding
the use and disclosure of your protected health information. These rights are more fully described in Beaufort
Center for Dentistry’s Notice of Privacy Practices. We are permitted to review our Notice of Privacy Practices at
any time. We will provide you with a copy of the revised Notice of Privacy Practices upon your request.
By signing below, you are acknowledging that you understand and have reviewed a copy of Beaufort
Center for Dentistry’s Notice of Privacy Practices.
_______________________________________________ ___________________________________
Patient or Guardian Printed Name Date
_______________________________________________ ___________________________________
Patient or Guardian Signature Relationship to Patient
FOR OFFICE USE ONLY
An attempt to obtain written acknowledgement of Receipt of our Notice of Privacy Practices was attempted,
however acknowledgement could not be obtained because:
☐ Individual refused to sign
☐ Communication barriers prohibited obtaining the acknowledgement
☐ Other. Please provide details below.