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Dr. Mark Phillips
Board Certified
Patient Reviews
Procedures
Root Canal
Retreatment
Cracked Teeth
Micro Surgery
Regenerative Endodontics
Advanced Technology
Patient Information
First Visit
Scheduling
Frequently Asked Questions
Write A Review
Financial Policy
Insurance
Privacy Policy
Post Surgery Care
Referring Doctors
Referral Information
Doctor Referral Form
Contact
Contact Info
Driving Directions
Home
Meet Us
Dr. Mark Phillips
Board Certified
Patient Reviews
Procedures
Root Canal
Retreatment
Cracked Teeth
Micro Surgery
Regenerative Endodontics
Advanced Technology
Patient Information
First Visit
Scheduling
Frequently Asked Questions
Write A Review
Financial Policy
Insurance
Privacy Policy
Post Surgery Care
Referring Doctors
Referral Information
Doctor Referral Form
Contact
Contact Info
Driving Directions
To speed up processing when you visit us, please fill out this online patient registration form and click "Submit". Your information will go directly to our office staff.
Patient Information
Date
*
Date
MM
DD
YYYY
Subject
*
Type "Patient Registration"
Name
*
Name
First Name
Last Name
Address
*
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Home Phone
Home Phone
(###)
###
####
Cell Phone
Cell Phone
(###)
###
####
Work Phone
Work Phone
(###)
###
####
Email Address
Date of Birth
Date of Birth
MM
DD
YYYY
Patient's Employer
Referred By Dr.
Please indicate who referred you to us.
Regular Family Dentist (if different than referring doctor).
MEDICAL HISTORY
Are you currently under a physician's care?
Yes
No
If yes, please give reason for treatment
Do you need to pre-medicate before dental treatment?
Example of medical problems requiring pre-medication (Mitrol Val Prolapse, Artificial Heart Valve, Hip/Knee Replacement)
Please list ANY medications you are currently taking (Include dosage and frequency).
ALLERGIES: List any medications (e.g. penicillin) or substances (e.g. latex) to which you are allergic or experience bad reactions.
Please check any illnesses you have had or suspected:
Heart murmur/leaky valve
Heart trouble
Chest pain
Shortness of breath
Diabetes
Cancer/tumor
Epilepsy
Stomach ulcer
Thyroid problems
Blood transfusion
Rheumatic fever
Heart attack (date________)
Bypass
Asthma
Liver disease
Kidney disease
Stroke
Reflux (GERD)
Glaucoma
Prosthetic/artificial joint
Prosthetic heart valve
High blood pressure
Sinus problems
Tuberculosis
Hepatitis
Dialysis
Immunocompromised
Hiatal hernia
Bleeding problems
Arthritis
Breastfeeding?
Yes
No
Are you taking oral contraceptives?
Yes
No
Do you have any problems with your Temporal Mendibular Joint (TMJ, TMD)?
Yes
No
Other health information not listed above?
PAYMENT POLICY
Credit Card Authorization and Verification Form. All Charges are due on the date of service. We accept Cash, Check, Major credit cards and CareCredit. We do not accept MNSure, Ucare, or Medicare.
How will you be paying today?
Cash
Check
Credit Card
CareCredit (I would like to apply for)
CareCredit (I have already applied)
I fully understand and will comply with this policy.
*
Yes
DENTAL INSURANCE
If you have and would like to use dental inurance, we are happy to accommodate you, but we must have a secondary payment in place to cover any unpaid charges. CareCredit, or a major credit card would be acceptable. “Credit cards will be authorized (not charged) for the total amount due on the date of service and any remaining balance will be charged, after the insurance payment is received.
I authorize Great Lakes Endodontics to charge my credit card for applicable charges.
Yes
Primary Dental Insurance Information
Name of Insurance Company
Subscriber ID
Group Number
Employee's Name
Employee's Name
First Name
Last Name
Employee's Date-of-Birth
Employee's Date-of-Birth
MM
DD
YYYY
Employee's Address
Employee's Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Thank you!