Patient Registration

Dental Interview

Patient Information

Dental Insurance

If yes, fill below

Group A

Assignment and Release

I certify that I, and/or my dependent(s), have insurance coverage with the above-named Insurance Company(ies) and assign directly to Dr. Toni Sartini all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named doctor may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.


Phone Numbers & Contact Information

IN CASE OF EMERGENCY, CONTACT: (Specify someone who does not live in your household)

Dental History

Please indicate with "Yes" or "No" if you have had any of the following:

Health History

Medical History

Please indicate with "Yes" or "No" if you have had any of the following:


Female Patients



Appointment Cancellation

I understand that I will be charged a fee of $75 if I fail to give Dr. Sartini's staff 24 hours notice for the cancellation for an appointment.

Consent for Dental Treatment and Acknowledgment of Receipt of Information

At the office of Dr. Toni Sartini, 845 St. NE, Palmayra, IN 47164

State Law requires us to obtain your consent for dental treatment. Please ask us about anything you do not understand. We are ready to answer any of your questions or explain anything you do not understand.

Any alternative to the recommended treatments, including no treatment, have been explained to me. In general terms the contemplated dental treatment is/are:

\tFillings with resin material

\tCrowns, inlays/onlays, bridges

\tProphylaxis(cleaning)/periodontal therapy

\tPost and/or cores

\tImplants/Crown or dentures

\tGingival removal

\tTeeth whitening

\tAny necessary xrays

\tLaser usage


There are risks associated with any dental treatment. This includes the administration of any local or general anesthetics agent, analgesic agents(s) to produce conscious sedations, and/or premedication prior to dental care being rendered. Some of the risks/complications are, but are not limit to, the following:



\tFailure of wound to heal

\tParasthesia or numbness of tongue, and/or mouth, and/or face

\tInjury to adjacent structures

\tAllergic reaction to drugs bacterial endocarditis

\tInjuries to adjacent teeth and/or hard or soft tissues

\tDeath (in rare instances)

\tInstrument breakage

\tLoss of teeth

Additional oral surgery, hospitalization and/or further treatment may be required in the even of any complication(s).


I acknowledge that I have read this consent form, or that it has been read to me, and that I understand the information contained on this consent form. I was given adequate opportunity to ask any questions and all questions that were asked were answered to my satisfaction.

I hereby authorize and direct the dentist and/or associate, hygienist, and/or assistants of their choice to perform the diagnostic, surgical or dental treatment recommended. This consent form will remain valid unless revoked by me in writing.


Acknowledgement of Receipt of Notice of Privacy Practices.

- You may refuse to Sign this Acknowledgement -

I, [ PATIENT NAME ], have received a copy of this office's Notice of Privacy Practices


Consent for Use and Disclosure of Health Information

Purpose of Consent: By signing this form, you will consent to our office use and disclosure of your protected health information to carry out treatment, payment and healthcare operations.


Patient Advisory and Acknowledgement -- Receiving Dental Treatment During the COVID-19 Pandemic

Dear Patient:

You have come to our office today for a routine dental evaluation and/or treatment that will be done during the COVID-19 pandemic. Please be advised of the following:

While our office complies with State Health Department and the Centers for Disease Control and Prevention infection control guidelines to prevent the spread of COVID-19 virus, we cannot make any guarantees.

Our staff are symptom-free and, to the best of their knowledge, have not been exposed to the virus. However, since we are a place of public accommodation, other persons (including other patients) could be infect, with or without their knowledge.

In order to reduce the risk of spreading COVID-19, we have asked you a number of "screening" questions below. For the safety of our staff, other patients, and yourself, please be truthful and candid in your answers.


Patient Screening Questionnaire

Please answer "yes" or "no" to the following questions: