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New Patient Registration

Please make sure to read our Dental Insurance Facts.

(*) - Required field

Please fill out our secure online form below. By completing and sending, it will be sent to our office confidentially.

Patient Information

Full Name
If Child, Parent's Name
Address
City
State
Zip
Phone Number
E-Mail Address
Social Security Number
Date of Birth
Age
Sex
Employer
If Student, School Name
Marital Status
If Married, Spouse's Name
Emergency Contact
Emergency Phone

Patient Medical History

Physician Name
Date of Last Physical
Reason for Visit

Are You Currently Under a Physician's Care?

Have You Ever Been Hospitalized?

General Dentist
Referred By
How Did You Hear About Us?
Other Family Members in This Practice
Date of Last Dental Visit
Date of Last Dental X-Ray
If Wearing Dentures, Age of Dentures

Ever Had Novocaine or Other Local Anesthetic?

Are You Taking or Have Taken Steroid or Cortisone Therapy?

Are You Taking or Have Taken Any Oral Bisphosphonates?

Are You Taking or Have Taken Any IV Bisphosphonates (Aredia, Zometa, Bonefos)?

Have You Taken Antibiotics Prior to Dental Procedures in the Past?

Are You a Smoker?

If So, How Much Do You Smoke? Or, How Long Ago Did You Quit?

Are You Pregnant?

If Pregnant, Your Estimated Delivery Date?

Are You Currently Nursing?

Please List All Medications You Are Allergic To

Have You Had an Adverse Reaction or Become Ill to Penicillin, Aspirin, Codeine, Local Anesthetics, Latex, Metals, or Any Other Medication or Substance?

Please List All Medications You Are Currently Taking

Do You Currently Take Fish Oil, Vitamin E, Omega 3, Plavix, Coumadin, Xarelto, or Aspirin Daily?

Consume More Than One Alcohol Based Drink Daily?

Do You Have Any Of The Following Problems With Your Mouth or Teeth? (Check All That Apply)

Medical Information

Services Requested

Bodnar Periodontics provides the following services, what are you interested in?

Primary Dental Insurance

Bodnar Periodontics is a dental provider and is unable to accept medical insurance, Medicare, and Medicaid

Subscriber Name
Subscriber ID
Subscriber SS#
Subscriber Date of Birth
Relationship, if Other Than Self
Employer
Employer Phone
Insurance Company
Insurance Group Number
State
Zip
Insurance Phone

Secondary Dental Insurance

Bodnar Periodontics is a dental provider and is unable to accept medical insurance, Medicare, and Medicaid

Subscriber Name
Subscriber ID
Subscriber SS#
Subscriber Date of Birth
Relationship, if Other Than Self
Employer
Employer Phone
Insurance Company
Insurance Group Number
State
Zip
Insurance Phone

Payment Options

At Bodnar Periodontics, we understand that affordability is an important consideration in getting the dental treatment you need and deserve. We offer a variety of payment options so that your treatment is within reach. If you think you may be interested in one of our payment programs, please contact our office for additional information.

Authorization And Release

I certify that I have read and understand the information completed to the best of my knowledge. The questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release my information, including diagnosis and the records of any treatment or examination rendered to me or my dependent during the period of such dental care to third party payers and/or health practitioners.

I authorize and request my insurance company to pay directly to Bodnar Periodontics insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services and any remaining balance will be my sole responsibility. I agree to be responsible for payment of all services rendered on my behalf or any dependents. If I have a change in my health, I will inform Bodnar Periodontics of this at the next appointment.

HIPAA Patient Consent

The Health Insurance Portability and Accountability Act

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

  • Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
  • Obtain payment for third-party payers.
  • Conduct Normal healthcare operations such as quality assessments and physician certification.

I have been informed by Dr. Bodnar of your Notice of Privacy Practices (located in the patient reception area) containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact the office at any time to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or health care operations. I also understand you are not required to agree to my request restrictions, but if you do agree then you are bound to abide by such restrictions.

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