Ellen Sheridan, DDS   Ellen Sheridan, DDS
104 Archibald St
Kansas City MO 64111-2230
816 531-0382
NEW PATIENT REGISTRATION FORM

You may fill in the form below and click Click the button at the bottom of the page button to format the
information into 3 condensed pages to print out and bring with you on the first visit.

If you would prefer to print out the forms, fill them in and bring them with you click here.
       
Patient Information: (*required)  
*First Name: MI: *Last Name: Preferred First Name:  
*Address 1: Address 2: *City: *State: *Zip:
 
Phones (*at least one is required. 10 digit number): Cell: Home: Pager: Work: ext  
*SSN: Medicaid ID: *Birthday MM/DD/YYYY: / / *Sex:  
Drivers License #/State: Email: May we communicate by e-mai?: Y N  
Marital Status: Employed: Student:  
Preferred Dentist: Preferred Hygenist: Preferred Pharmacy (name/phone#):  
Previous Dentist: Referred by: Emergency Contact Name: Emergency Contact Phone:  
Responsible Party Information: (*required)  
Check here if the Patient is also the Responsible Party  
*First Name: MI: *Last Name:  
*Address 1: Address 2: *City: *State: *Zip:  
Phones (*at least one is required): Cell: Home: Pager: Work: ext:  
*Birthday MM/DD/YYYY: / / *SSN: Driver's License #/State:  
Primary Insurance Information:
Check here if Patient is the Primary Insurance policy holder Check here if Responsible Party is the Primary Insurance policy holder
First, Middle, Last name of Insured: Relationship to the patient:
SSN: Birthday MM/DD/YYYY: / /
Employer: Insurance Company Name:
Address 1: Address 1:
Address 2: Address 2:
City: State: Zip: City: State: Zip:
Secondary Insurance Information:
Check here if Patient is the Secondary Insurance policy holder Check here if Responsible Party is the Secondary Insurance policy holder
First, Middle, Last name of Insured: Relationship to the patient:
SSN: Birthday MM/DD/YYYY: / /
Employer: Insurance Company Name:
Address 1: Address 1:
Address 2: Address 2:
City: State: Zip: City: State: Zip:
Medical History:
//
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.
Are you under a physician's care now? Y N if yes, explain
Have you ever been hospitalized or had a major operation? Y N if yes, explain
Have you ever had a serious head or neck injury? Y N if yes, explain
Are you taking any medications, pills, or drugs? Y N if yes, list medicines
Do you take, or have you taken, Phen-Fen or Redux? Y N  
Have you ever taken Fosamax, Boniva, Actonel or any
other medications containing bisphosphonates?
Y N Women:
Are you on a special diet? Y N Are you pregnant or trying to get pregnant? Y N
Do you use tobacco of any type? Y N Are you nursing? Y N
Do you use controlled substances? Y N Taking oral Contraceptives? Y N
Are you allergic to any of the following:    

Aspirin Penicillin Codeine Acrylic Metal Latex Local Anesthetics Sulfa Drugs
Other:

AIDS/HIV Positive ColdSores Fever Blisters Glaucoma Leukemia Sickle Cell Disease
Alzheimers Disease Congenital Heart Disorder Hay Fever LiverDisease Sinus Trouble
Anaphylaxis Convulsions Heart Attack/Failure Low Blood Pressure Spina Bifida
Anemia Cortisone Medicine Heart Murmur Lung Disease Stomach/Intestinal Disease
Angina Diabetes Heart Pacemaker Mitral Valve Prolapse Stroke
Arthritis Gout DrugAddiction Heart Trouble Disease Osteoporosis Swelling of Limbs
Artificia lHeart Valve EasilyWinded Hemophilia Pain in Jaw Joints Thyroid Disease
Artificial Joint Emphysema Hepatitis A Parathyroi Disease Tonsillitis
Asthma Epilepsy or Seizures Hepatitis B or C Psychiatric Care Tuberculosis
Blood Disease Excessive Bleeding Herpes Radiation Treatments Tumorsor/Growths
Blood Transfusion Excessive Thirst High Blood Pressure Recent Weight Loss Ulcers
Breathing Problem Fainting Spells Dizziness High Cholesterol Renal Dialysis Venereal Disease
Bruise Easily Frequent Cough Hivesor/Rash Rheumatic Fever Yellow Jaundice
Cancer Frequent Diarrhea Hypoglycemia Rheumatism  
Chemotherapy Frequent Headaches Irregular Heartbeat ScarletFever  
ChestPains Genital Herpes Kidney Problems Shingles  
Have you ever had any serious illness not listed? Any other medical comments you wish to make?
By entering my name below I confirm that to the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or the patient's) health. It is my responsibility to inform the dental office of any changes in medical status.
*First/Middle/Last Name:
Financial Agreement: (*required)
This financial agreement is between Ellen A Sheridan, D.D.S. 104 Archibald St, Kansas City, MO 64111 816-531-0382
and
If you have dental benefits, we will help you receive maximum benefits by filing for you. We will
expect payment of estimated copays, coinsurance and deductibles at the time of service. We accept
Mastercard, Visa, Check and Cash. Financing is offered through Care Credit.

As a patient (or guardian of a patient) I understand that this office does not acknowledge agreements
between parents accepting or denying responsibilities of services provided. We consider the custodial
guardian/parent to be responsible for payment of services received.

Assignment of Insurance Benefits
I hereby assign benefits to be paid, on my behalf, to Ellen A. Sheridan, D.D.S. I understand and agree
to be financially responsible for charges not covered or paid by dental benefits.

By entering my name below I acknowledge the above financial agreement.

This agreement is made on behalf of
by: *First/Middle/Last Name:
on as the following relationship to the patient *

NOTE: THE RESPONSIBLE PARTY WILL BE REQUIRED TO SIGN THIS DOCUMENT ON THE
DAY OF THE FIRST VISIT BY THE PATIENT.

Notice of Privacy Practices Acknowledgement

Ellen A. Sheridan, D.D.S.
104 Archibald Street
Kansas City, MO 64111

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
providcrs who may be involved in that treatment directly and indirectly.
• Obtain payment from third-party payers.
• Conduct normal healthcare operations such as quality assessments and physician
certifications.

I have received. read and understand your Notice of Privacy Practices containing a more
complete description of the uses and disclosures of my health information. I understand
that this organization has the right to change its Notice of Privacy Practices from time to
time and that I may contact this organization at any time at the address above to obtain a
current copy of the Notice of Privacy Practices.

Click here to view/print the HIPPA 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 healthcare operations. I also
understand you are not required to agree to my requested restrictions, but if you do agree
then you are bound to abide by such restrictions.

This document is acknowledged on behalf of
by *First/Middle/Last Name:
on as the following relationship to the patient *