(973) 334-5556

150 River Road Suite J-2
Montville, NJ 07045

Online Registration Forms

Online Registration Forms

For your convenience, you may complete your registration forms on this page and submit through our secure portal for quick and easy processing. If you prefer to download the forms, you may do so here.

Patient Information

Patient Name:

Preferred Name:

Date:

Birthdate:

Sex:

Male Female

Martial Status:

Single Married Divorced Other

 

Who is the person completing this form?
Self Spouse Father Mother Other

Home Phone:

Work Phone:

Cell Phone:

 

Address:

City:

State:

Zip:

 

Email Address:

Communication Preferences(s)?

Text

Email

US Mail

All of the Above

 

State ID/Driver's License #:

SS#:

 

Emergency Contact:

Relationship:

Phone:

 

How did you hear about our office? (If referral, please list name):

Billing Information


Self (If self, skip this section) Spouse Father Mother Other

 
Primary Insurance

Dental Medical

Yes (If yes, skip the following)

No

Secondary Insurance

Dental Medical

Yes (If yes, skip the following)

No

Patient Health History

Do you have a history of: (Please Check Yes or No)

AIDS/HIV Positive

Yes No

Alcoholism

Yes No

Allergies

Yes No

Anemia

Yes No

Anxiety

Yes No

Arthritis

Yes No

Artificial or Prosthetic Joint Replacement

Yes No

Artificial or Prosthetic Heart Valve

Yes No

Asthma

Yes No

Blood Disease

Yes No

Bone Disease

Yes No

Cancer

Yes No

Chemotherapy/Radiation Treatment

Yes No

Chest Pain

Yes No

Convulsions/Seizures/Epilepsy

Yes No

Depression

Yes No

Diabetes

Yes No

Drug Use

Yes No

Excessive Bleeding

Yes No

Excessive Thirst/Urination

Yes No

Fainting Spells

Yes No

Hay Fever

Yes No

Head Injuries

Yes No

Hearing Impaired

Yes No

Cardiovascular Disease

Yes No

Heart Valve Disease/Murmur

Yes No

Hepatitis/Liver Disease

Yes No

High Blood Pressure

Yes No

Immune Disorder

Yes No

Kidney Disease

Yes No

Latex Sensitivity

Yes No

Lupus

Yes No

Low Blood Pressure

Yes No

Malignancies

Yes No

Mitral Valve Prolapse

Yes No

Neck & Back Problems

Yes No

Nervous Problems or Disorders

Yes No

Organ Transplant

Yes No

Pacemaker

Yes No

Psychiatric Care

Yes No

Respiratory/Pulmonary Problems

Yes No

Rheumatic Fever/Heart Disease

Yes No

Rheumatoid Arthritis

Yes No

Sexually Transmitted Disease

Yes No

Shortness of Breath

Yes No

Sinus Problems

Yes No

Stomach Ulcers

Yes No

Stroke

Yes No

Thyroid Disease

Yes No

Tuberculosis

Yes No

Tumors or Growths

Yes No
 

Medications

Are you ALLERGIC to any medications?

Yes No If yes, please list:

Do you require premedication prior to dental treatment that you are aware of?

Yes No If yes, please explain:

Do you have any other disease/problem you think we should know about?

Yes No If yes, please explain:

Yes No

Are you now under the care of a physician?

Yes No If yes, please provide name and tel. no.:

Yes No If yes, when/why?

Yes No If yes, when/why?

Are you taking or have you ever taken any medications for cancer, osteoporosis, osteopenia, Paget's Disease, or multiple myleoma (including, but not limited to bisphosphonates e.g. Fosamaz, Boniva, Actonel, Zometa, Recliast, or Prolia)? Yes No If yes, when/why?

Yes No If yes, how many packs/day and for how long?

Women Only

Yes No

Yes No

Yes No

Dental History Information

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

If yes, please explain

Yes No
 

I certify that I have read and under stand the questions above. I acknowledge that my questions have been answered to my satisfaction. I will not hold my dentist or any other members of his/her staff responsible for any errors and or/omissions that I have made in the completion of this form.

I further authorize the dentist or designated staff to take x-rays, study models, photographs, and/or employ other diagnostic aids deemed appropriated by the dentist to facilitate a diagnosis. Upon diagnosis, I authorize the dentist to perform all recommended treatment mutually agreed upon by me, which may include the use or anesthetics, sedatives and other medications.

I hereby acknowledge that a copy of this office's Notice of Privacy Practices (click here) has been made available to me and acknowledge all disclosures relative to my treatment by Krause Comprehensive Dental Care.

Financial Policy

We are committed to providing you with the best possible care, and we are pleased to discuss our professional fees with you at any time. Your clear understanding of our Financial Policy is important to our professional relationship. Please ask if you have any questions about our fees, financial policy, or your responsibility.

PAYMENT
Payment is due in full at the time services are rendered, unless prior financial arrangements have been made. For convenience, we accept payment in the form of cash, checks, credit and debit cards.

REGARDING INSURANCE
We file insurance claims as a courtesy to our patients and our office is dedicated to helping our patients maximize their benefits. Upon verification of coverage, we will complete your claim form so that you can be reimbursed by your insurance company to the extent of your coverage. Some carriers pay a fixed allowance for a procedure, while others pay a percentage of the fees charged. It is your responsibility to pay deductibles, co-payments and any balance not paid by the insurance carrier. Insurance is a contract between you and your insurance company. We are not a party to this contract in most cases; therefore, you are solely responsible for your benefits and eligibility information. (We will inform you if we are a party to your insurance contract, and will handle your claims according to our agreement with the insurance company, if one exists.) We will not become involved in disputes between you and your insurance company regarding deductibles, co-payments, covered charges, secondary insurance, "usual and customary" charges, etc., other than to supply factual information as necessary. You are ultimately responsible for the timely payment of your account.

Please note that any insurance payment estimates provided as part of your treatment plan are solely estimates generated by our practice management software. These are NOT guarantees of payment. For more accurate information on insurance payment towards any specific treatment, you may inquire directly with your insurance carrier or request the processing for a pre-determination of benefits. Please understand that most insurance carriers will also not guarantee benefits presented in a pre-determination, and this process can often delay treatment for several weeks. If your insurance company has not paid the FULL BALANCE within 45 days, you have 15 days to pay the balance. If your insurance company pays more than the balance due, we will send a refund check to you immediately.

DELINQUENT ACCOUNTS
Late Payment Charges (1.5% per month) are added to unpaid accounts after 60 days from date of service. There will also be a $40 fee for any returned check. In the case of default of your account you will pay collection costs, interest on the unpaid balance until paid in full, and attorney fees incurred in attempting to collect on your present and future account balance. Collection accounts may be reported to credit service bureaus, when appropriate.

MISSED APPOINTMENTS
Unless cancelled at least 24 hours in advance, our policy is to charge for missed appointments at the rate of a normal office visit. Please help us serve you better by keeping your scheduled appointments.

By signature below, I accept the terms of this Financial Policy and I authorize release of any information relating to a claim, to all of my insurance companies, as warranted. I further authorize payment on a claim directly to the doctor for benefits otherwise payable to me, unless alternate arrangements have been previously made. My signature also applies to all dependents listed on my account.