809 Sylvan Ave., Suite 300, Modesto, CA 95350
209-572-6008 | Fax: 209-572-6009
Patient Registration
Patient is:
Patient Information
Marital Status:
*required for insurance policy holders
Employment Status:
Student Status:
Responsible Party
(If someone other than the patient)
*required for insurance policy holders
Primary Insurance Information
*required for insurance policy holders
Relationship To Patient:
Secondary Insurance Information
*required for insurance policy holders
Relationship To Patient:
Health History
Our primary goal is patient safety, and although our 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.
Are you under a physician care now?
Have you ever been hospitalized or had a major operation?
Have you ever had a serious head or neck injury?
Are you taking any prescription medications?
Are you taking any over the counter medications?
Do you use tobacco? cigarettes, cigars, chewing tobacco, e-cigarettes
Do you use controlled substances?
(including marijuana/THC)
Have you ever taken Fosamax, Boniva, Actonel, or any other medications containing bisphosphonates?
Are you on a special diet?
WOMEN, please check all that applies:
Check if you are allergic to any of the following:
Do you have, or have had, any of the following?
AIDS/HIV Positive
Alzheimer's Disease
Artificial Heart Valve
Artificial Joint
Blood Disease
Blood Transfusion
Breathing Problems
Bruise Easily
Chest Pains
Chronic Sinus Trouble
Cold Sores/Fever Blisters
Congenital Heart Disorders
Congestive Heart Failure
Cortisone Medication
Diabetes - Type 1
Diabetes - Type 2
Drug Addiction
Easily Winded
Epilepsy or Seizures
Excessive Bleeding
Fainting Spells/Dizziness
Frequent Cough
Frequent Headaches
Gastric or Intestinal Ulcer
Hay Fever
Heart Attack/Failure
Heart Disease
Heart Murmur
Heart Pacemaker
Hepatitis A
Hepatitis B
Hepatitis C
High Blood Pressure
High Cholesterol
Hives or Rash
Irregular Heartbeat
Kidney Disease
Liver Disease
Low Blood Pressure
Lung Disease
Mitral Valve Proplapse
Pain In Jaw Joints
Parathyroid Disease
Psychiatric Care
Radiation Therapy
Recent Weight Loss
Renal Dialysis
Rheumatic Fever
Rheumatoid scarlet-fever
Scarlet Fever
Sickle Cell Disease
Sleep Apnea
Spina Bifida
Stomach/Intestinal Disease
Swelling of Limbs
Thyroid Disease
TIA (mini-stroke)
Tumors of Growths
Have you ever had any serious illness not listed above?
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 patient's) health. It is my responsibility to inform the dental office of any changes in my medical status of medications.
Release Form

Welcome to our practice. We appreciate your selection of our office to serve your dental health needs. Our goal is to provide the very best possible dental and periodontal care for our patients.

Please read the following statements. The patient or legal guardian must agree and sign.

General Release

The undersigned hereby authorizes the doctor to take radiographs, study models, photographs, or any other diagnostic aids deemed appropriate to make a thorough diagnosis of the patient's dental needs. I further authorize and consent that the doctor may consult with my physician or other health care providers regarding my periodontal treatment. I also authorize the doctor to perform any form of treatment, medication, and/or therapy that may be indicated. I understand that the use of anesthetic agents and certain treatments embody some risk. In good faith, the doctor will present these risks and alternatives to proposed treatment and my questions will have been answered in order to proceed.

Patient Contact
I consent to the Clarke V. Filippi, DDS, Inc. Periodontal Practice using my cell phone number to:

Regarding appointments and to call regarding treatment, insurance, and my account. I understand that I can withdraw my consent at any time.

Financial Responsibilities

Part of our commitment to patient care is to provide you with information about your dental needs and treatment, including the estimated costs of your quality care. Our fees are individually based on the time, severity, and difficulty of your specialty treatment. Payment not covered by your insurance is expected at the time of service. We accept cash, check, ATM, and credit card payments. A $25.00 fee is charged an all returned checks. A 1.5% service charge will be assessed on all accounts not settled within 90 days of service.

I understand that I am responsible for any payment due for services that I have received. In addition to the portion of the services not covered by my insurance carrier, I am responsible for any outstanding balance after the insurance carrier has been estimated and/or billed. I also understand that payment not covered by my insurance is expected at the time of service. If the Clarke V. Filippi, DDS, Inc. Periodontal Practice is subsequently paid by the insurance carrier I will be reimbursed.

Finally, I understand that the Clarke V. Filippi, DDS, Inc. Periodontal Practice reserves a specific time for me on their appointment schedule and that not confirming an appointment, cancelling an appointment without 24-hour notice or not showing to an appointment does not allow time for that vacancy to be filled. Therefore, I am hereby notified that this office reserves the right to charge for and cancel unconfirmed, missed appointments or those cancelled without 24-hour notice.

Acknowledgement Of Receipt Of Notice Of Privacy Practices

*You May Refuse to Sign This Acknowledgment*

I have received a copy of this office's Notice of Privacy Practices.

View Notice of Privacy Practices

For Office Use Only

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: