Del Kovacevic - Registration

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Patient Registration
Name
First Middle Last
Gender
- Male
- Female
Family Status
- Married
- Single
- Child
- Other
Birth Date
Social Security Number
Email
Phone Numbers (select all that apply)
- Cell Phone
- Home Phone
- Work Phone
Best time to call
Cell Phone
Home Phone
Work Phone
Address
Street Address City State / Province / Region ZIP / Postal Code
How did you hear of our office?
Whom may we thank for referring you?
The following is for
Who is responsible for payment
Employer Name
Employer Phone Number
Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
About Your Spouse or Guardian
Name
First Middle Last
Gender
- Male
- Female
Family Status
- Married
- Single
- Other
Birth Date
Social Security Number
Email
Phone Numbers (Select all that apply)
- Cell Phone
- Home Phone
- Work Phone
Best time to call
Home Phone
Cell Phone
Work Phone
Address
Street Address City State / Province / Region ZIP / Postal Code
Primary Dental Insurance
Name of Insured
First Middle Last
Insured's Birth Date
ID Number
Group Number
Employer Name
Employer Phone
Address
Street Address City State / Province / Region ZIP / Postal Code
Position or Title
Patient's Relationship to insured
- Self
- Spouse
- Child
- Other
Insurance Plan Name
Insurance Phone Number
Insurance Address
Street Address City State / Province / Region ZIP / Postal Code
Secondary Insurnace
- Yes
- No
Secondary Dental Insurance
Name of Insured
First Middle Last
Insured's Birth Date
ID Number
Group Number
Employer Name
Employer Phone
Address
Street Address City State / Province / Region ZIP / Postal Code
Position or Title
Patient's Relationship to insured
- Self
- Spouse
- Child
- Other
Insurance Plan Name
Insurance Phone Number
Insurance Address
Street Address City State / Province / Region ZIP / Postal Code

Medical History
Name
First Last
Today's Date
For the following questions, please check ALL that apply.
THESE FACTS HAVE A DIRECT BEARING ON YOUR DENTAL HEALTH.
Height
Weight
Race
General Medical History:
Are you in good general health?
- Yes
- No
Has there been any change in your general health in the past year?
- Yes
- No
My last physical examination was on appoximate date
Are you PRESENTLY under a physician's care?
- Yes
- No
If YES, what condition?
Physician's Name
First Last
Physician's Address
Street Address City State / Province / Region ZIP / Postal Code
Physician's Phone
Have you had any serious illness or operation?
- Yes
- No
If YES, please list
Within the past 5 years?
- Yes
- No
If YES, please list
Cardiovascular System
If YES, check all that apply
- Congenital heart disease
- Coronary insufficiency
- Mitral Valve Prolapse
- Damaged Heart Valves
- Stroke
- Rheumatic heart disease, heart murmur
- Chest pain after exertion
- Shortness of breath after mild exercise
- Swollen ankles
- extra pillow to sleep
- cardiac pacemaker
- High blood pressure
- Low blood pressure
Central Nervous System
If YES, check all that apply
- Epilepsy
- Fainting spells
- Seizures
- Emotional disturbance
- treatment for a nervous disease
Respitory System
If YES, check all that apply
- persistent cough or cold
- have or have you ever had tuberculosis
- ANY history of tuberculosis in your family
- any sinusitis, sinus trouble
- emphysema, chronic bronchitis or asthma
Digestive System
If YES, check all that apply
- Do you have any stomach ulcers
- Acid Reflux
- Hepatitis
- Jaundice
- Liver Disease
- Have you ever vomited blood
- Do you have ANY diarrhea
Endocrine System
If YES, check all that apply
- Do you have Diabetes controlled
- Do you have Diabetes uncontrolled
- Does anyone in your family have diabetes
- Do you urinate more than 6 times a day?
- Are you thirsty very often or do you have a dry mouth
- Do you have hypothyroidism of hyperthyroidism
Hemotogenic System
If YES, check all that apply
- Do you have anemia, Sickle Cell disease, blood disorders
- Is there ANY family history of blood disorders
- Are you hemophilic
- Have you had abnormal bleeding after any surgery, extraction, or trauma
- Have you ever had a blood transfusion
- Immunodeficiency problem

Allergies
If YES, check all that apply
- Local anesthetic
- Antibiotics, Penicillin, Sulfa drugs
- Barbiturates, sedatives or sleeping pills
- Aspirin
- Iodine
- Codeine or other narcotics
- Latex
- Do you have asthma, hay fever or seasonal allergies
- Do you have or have you ever had hives or skin rash
Genitourinary System
If YES, check all that apply
- Kidney trouble
- Dialysis
- Syphilis, gonorrhea
Bones & Joints
If YES, check all that apply
- Arthritis
- Inflammatory rheumatism
- Bone infection
- Osteoporosis
- Artificial Joint Replacement
- PART 1: Have you received or are you currently receiving the intravenous medication know as bisphosphonate
- PART 2: Are you taking or have you taken the oral medication known a bisphosphante for osteoporosis or another medical condition
If YES to part 1 or 2
- Have you noticed any changes in your mouth or jaws
- Have you had any jaw pain or toothache
- Have you noticed any foul smell, swelling or discharge in your mouth
Other
If YES, check all that apply
- Tumor or malignancy
- Chemotherapy or radiation therapy
- Are you regularly exposed to x-rays or ANY other ionizing radiation or toxic substance
- Do you have wide glaucoma
- Do you have close glaucoma
- Are you wearing or do you wear contact lenses
- Do you drink alcohol
- Do you use tobacco
How often do you drink alcohol
How often do you use tobacco
For Women
If YES, check all that apply
- Are you pregnant
- Are you nursing
- Do you have any problems associated with your menstrual period
- Are you taking oral contraceptives
- Are you undergoing hormonal therapy
Dental History
If YES, check all that apply
- Are you experiencing any discomfort or pain at this time
- Are you satisfied with the appearance of your teeth
- Are you able to eat and chew foods satisfactorily
- Do you have headaches, ear aches, or neck pain
- Do you frequently experience sinus problems
- Have you had ANY serious trouble associated with ANY previous dental treatment
- Have you had a Full Mouth Series of x-rays or Panorex within the last 3-5 years
- If so, is it possible to have copies sent to our office
How long has it been since your last dental visit
Do you recall what was done at that time
Did you have x-rays taken at that visit
If YES, check all that apply
- Have you had a Full Mouth Series of x-rays or Panorex within the last 3-5 years
- If so, is it possible to have copies sent to our office
Are you taking any of these medications, if YES, check all that apply
- Antibiotics or Sulfa drugs
- Anticoagulants, blood thinning agents
- Medicine for high blood pressure
- Tranquilizers
- Iodine
- Aspirin
- Codeine or other narcotics
- Steroids
Others? Please explain
List Medications
Please list any type of medication you are presently taking as well as the dosage.
Name/Type of Drug Dosage How many times per day
General Dental Responsibility and Consent Statement
I also give my consent to ANY advisable and necessary dental procedures, medications or anesthetics to be administered by the attending dentist or his supervised staff for diagnostic purposes of dental treatment. These records may include study models, photographs, x-rays and blood studies. I understand and acknowledge that I am financially responsible for the services provided for myself and or the above named, regardless of insurance coverage. Treatment plans involving extended credit circumstances are subject to a credit check. I also understand that the treatment plan presented to me is only an estimate. Occasionally, the need may arise to modify treatment. In such a case, I will be informed of the need for additional treatment, and any fee modification. To the best of my knowledge the information in this form is accurate.
Signature of Patient or Guardian
Signature
Date
Signature of Witness
Signature
Date
Signature of Doctor
Signature
Date
Appointment Commitment Policy
As your time is valuable, we want to assure you that you will be seen on time for your appointment. Likewise, we would appreciate a 24 hours notice should you every have to change an appointment, so that another patient in need may receive care. We will make every effort to make your visit as pleasant and comfortable as possible.
Signature
Date
Photography Release
I authorize the use of my radiographs and/or photographs for use in seminars or publication of Dr. Del Kovacevic.

Signature of Patient of Guardian of minor
Signature
Date
FINANCIAL POLICY

In order to provide you with the highest quality dental care available, we provide our patients with estimates of dental treatment and fees. Patient, parent and/or guardian are responsible for the patient portion at the time of service. Financial options that we provide at this time:
- Cash or check
- Major credit card (Visa, Master Card, Discover)
- Extended Payment Options (Care Credit – based on credit approval)
Regarding Dental Insurance: Dr. Kovacevic and staff realize how important dental insurance benefits are to our patients. It is the responsibility of the patient to keep us informed of changes in insurance carriers, and to provide copies of insurance cards. We ask that you carefully review your policy so you are aware of benefits, deductibles, frequencies, and limitations or restrictions. Dental insurance is a contract between you and your insurance company; our role is to assist with filing claims and collection of payments. Ultimately, all dental services are charged directly to you, the patient, and you are personally responsible for payment of all dental services, within sixty days of your visit, regardless of insurance coverage. Please be aware that your insurance plan may have a yearly allowance (maximum) and charges exceeding that amount will be your responsibility. Also, should you have coverage from two insurance plans, please note that not all secondary policies will cover remaining portions.For a more accurate treatment estimate, we will be glad to pre-determine any treatment you may need, but it may take 4-6 weeks. Please do not allow your insurance to dictate the level of treatment you receive. Your dentist is here to provide the highest quality of care for you and/or your family regardless of insurance. You should receive an Explanation of Benefits the same time our office receives payment. Please be advised that it may be necessary to re-submit claims for payment, and occasionally, for various reasons, claims may be rejected. We will do our best to obtain payment for you, but we cannot render services based on the assumption that insurance will cover all claims, at all times. If any dental services have been provided by any other dental provider within the existing benefit year, please let us know. For Out-of-Network Insurance Plans, options are:
- Pre-Determination of treatment – to obtain accurate policy allowances and co-pays.
- Payment may be paid in full at the time of service, and a refund given once insurance payment has been received.
- A credit card may be left on file. Once the insurance payment is received, the remaining balance will be applied to the credit card
- Care Credit – no interest payment plan
Estimated co-pays and deductibles are due at the time of service. For multiple appointment procedures, such as major restorations (onlays, crowns, veneers), and prosthetics (implants, partials, dentures), final payment is expected prior to the final insert appointment.

I HAVE READ AND ACCEPT THE TERMS AND CONDITIONS OF THIS AGREEMENT.
I AUTHORIZE MY INSURANCE COMPANY TO PAY MY DENTAL BENEFITS DIRECTLY TO THIS OFFICE.
Signature

Dr. Del Kovacevic
700 Pellis Rd.
Greensburg, PA 15601
(724)836-2433
del.kovacevic@att.net

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY

Purpose of consent: By signing this form, I consent to the use and disclosure of my protected health information to carry out treatment, payment activities, and healthcare operations.
Notice of Privacy Practices: I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
I have been informed of and given the right to review and secure a copy of your Notice of Privacy Practices which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.

I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.

Right to Revoke: I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected. I understand that you may decline to treat me, or continue treatment, if I revoke this consent.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice at any time by contacting the office.

Signature:
I have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities, and health care operations.
Signature
Date
Relationship to Patient
- Self
- Spouse
- Child
- Other
Email
This field is for validation purposes and should be left unchanged.