Franklin Smiles
Patient Registration
1214 Murfreesboro Rd, Suite 210
Franklin, TN 37064
We are dedicated to the concept that all people have the opportunity to retain their teeth throughout their
lifetime with optimum health, function, comfort and esthetics. We realize the importance of your smile and
are committed to offering the best that dentistry has to offer-providing quality restorative dentistry with
special emphasis on cosmetics. Thanks for coming!
Last Name: ______________________________
First Name: _________________________________
Gender: _
___M ____F
Marital Status: ____Married ____Single ____Other
irth: _______________________
Social Security #: _______________________
Email Address: _____________________________________________________
dress: ________________________________________ City: ________________ ST____ Zip: ________
Home Phone: ___________________ Business Phone: _________________ Cell Phone: _________________
How did you hear about our office? _________
(Medical insurance does not apply-provide dental insurance information only)
Name of Employer: __________________________________
Name of

Subscriber: ____________________________ Subscriber ID: ___________________________
ber Date of Birth: _________________________ Group #: _________________________
Insurance Company: ___________________________
ng Address for Dental Claims:
City: _______________________ ST: _________ Zip: __________

Phone: _______________________________

Franklin Smiles and Dr. J. A. Reynolds are not contracted providers with any insurance company.
Please contact your carrier to determine how this will affect your benefits.
Any unpaid balances will be your responsibility.

MEDICAL HISTORY (circle all that apply)
Other: ____________________________________________________ DRUG ALLERGIES or Other Allergies (circle all that apply)
Other: ________________________________________________________________ ARE YOU TAKING ANY MEDICATIONS? ___Yes ____No (If yes, list below)
___________________________________________________________________________________________ _________ __________________________________________________________________________________ _________ __________________________________________________________________________________ _________ __________________________________________________________________________________ OR WOMEN ONLY
Are you pregnant? ____Yes ____No (If yes, when are you due? _______________) Are you taking birth control pills? _____Yes _____No DENTAL HISTORY
Date of Last Cleaning/Exam _____________________ Name of previous dentist: _______________________________ Have you ever had orthodontics, periodontal surgery, or other major medical treatment? If yes, explain: _________ _______________________________________________________________________________ ld you like Dr. Reynolds to do for you? List any items you wish to discuss with Dr. Reynolds: __________________________________________________________________________________________________________ ____________________________________________________________________________________________
Please ind
icate yes or no (Y/N) to the following:
___ Do you have any areas where food impacts around your teeth? ___ Do your gums tend to bleed easily, feel irritated or tender? ___ Are your teeth sensitive to hot, cold, pressure or sweets? ___ Do you have pain in your head, neck, shoulder, or upper back? ___ Do yo u have popping, clicking, or other noises in your jaw joints? ___ Are yo u aware of grinding or clenching your teeth? ___ Have y ou ever had any negative reactions to a dental injection or nitrous oxide? ___ Are yo u anxious or nervous about dental treatment? Is the appearance of your smile important to you? Rate the importance on a scale of 1 to 10: ________
By signing this form I am consenting to the use and disclosure of protected health information to carry out

ent, payment activities, and healthcare operations. I understand that the information above is necessary
de dental care in a safe and efficient manner. The answers provided above are correct and complete.
ng this form, you agree to inform this office of any changes in your medical history. Your signature
s you understand that Dr. Reynolds is HIPPA compliant and all precautions will be taken to protect
By signing this form, I understand the financial responsibility for dental services provided in this office for myself
and/or my dependents is mine. Insurance is filed as a courtesy and I understand I will pay any estimated portions
and any portions not paid by insurance. I further understand payment is due at time of service.

By signing this form, I agree to provide current and correct insurance information to Dr. Reynolds. I agree to
pay the estimated patient portion at the time of service. I understand that any balance NOT paid by insurance
is my full responsibility.
I understand Dr. Reynolds is not a contracted provider with any insurance company and it is my responsibility
to research my policy for limitations regarding out-of-network providers.
*I understand if the insurance company has not provided payment within 60 days of the submission
date, the claim will be closed and the remaining balance becomes my full responsibility.

Signature indicates you have read, and agree, with the items above:

Signature: ____________________________________ DATE ___________________

If patient is a child, please read & sign below:
I understand that the information above is necessary to provide my child with dental care in a safe and
efficient manner. To my knowledge answers are correct and complete. Realizing that the use of anesthetic
agents embodies certain risks, I will inform this office of any changes in my child’s medical history. I
further authorize and consent that Doctor Reynolds and/or his assigned may utilize diagnostic aids
deemed appropriate and perform all forms of treatment, medication, and therapy deemed necessary in
connection with the dental care of patient until written notice is given discontinuing this permission.

Patient or Guardian Signature_________________________ Date ______________
Relationship to Patient ______________________________________


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