New Patient Form

Title

Last Name

First Name

Preferred Name

Sex

M F

DOB

SS#

Do you have any immediate family members that come here?

Y N

If yes, please write relation

Mailing Address

City

State

Zip

Home Phone

Cell Phone

Other

Preferred Contact Phone

Home

Cell

Other

Email address

Would you like to receive email(s)?

Yes No

Occupation

Employer

Whom may we thank for referring you to us?

Emergency Contact:

Name

Relationship

Contact Phone

PERSON RESPONSIBLE FOR ACCOUNT

Patient

Guardian

Spouse

Father

Mother

PRIMARY DENTAL INSURANCE

If no insurance, complete this section for the person responsible for this account.

Last Name

First Name

Mailing Address

City

State

Zip

Home Phone

Cell Phone

Other

Preferred Contact Phone

Home

Cell

Other

Email address

DOB

SS#

Drivers Lic.

Relationship to Patient

Employer

Dental Ins. Co.

Subscriber ID

Group #

SECONDARY DENTAL INSURANCE

Last Name

First Name

Mailing Address

City

State

Zip

Home Phone

Cell Phone

Other

Preferred Contact Phone

Home

Cell

Other

Email address

DOB

SS#

Relationship to Patient

Employer

Dental Ins. Co.

Subscriber ID

Group #

PAYMENT/AUTHORIZATION

I understand that payment is due in full at each visit unless otherwise agreed upon in writing. I hereby authorize payment directly to Mountain Bay Dental of the group insurance otherwise payable to me. I understand I am responsible for all costs of dental treatment. I hereby authorize Paxton Family Dental to administer such medications and perform such diagnostic, photographic and therapeutic procedures as may be necessary for proper dental care. The information on this page is correct to the best of my knowledge. I grant the right to the dentist to release my dental/medical histories and other information about my dental treatment to third party payers and/or other health professionals.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient/Responsible Party Signature

Date

MEDICAL HISTORY

Other

If selected artificial joints, indicate date placed.

Are you on blood thinners?

Yes No

Please list any heart conditions

Please list any surgeries you have had

Are you under a Physicians care?

Yes No

If yes what for?

Please list or provide a list of all medications you are taking

For Women Are You

Pregnant?

Y N

Nursing?

Y N

Taking Birth Control?

Y N

*NOTE: If you are pregnant you will need a written note from your OBGYN prior to being seen.

DENTAL HISTORY

Do you have or have had any of following?

Dentures Partials Braces Periodontal (gum) treatments

Please check any of the following problems that apply to you.

Sensitivity to hot/cold/sweet

Headaches, earaches, neck pain

Jaw joint pain

Bad breath

Loose, tipped or shifting teeth

Bleeding, swollen, irritated gums

Grinding or clenching teeth

Reason for your visit today

Do you smoke or chew Tobacco?

Y N

How much?

How long?

If known, please list the following dates:

Last Exam

Last X-Rays

Who was your last dentist?

Reason for leaving?

I would like to

Replace missing teeth

Repair chipped teeth

Straighten teeth/Close spaces

Whiten teeth

Patient/Guardian Signature

Date

Doctors Signature

Date

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (“HIPPA”), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in my treatment directly or indirectly.
Obtain payment from third party payers.
Conduct normal healthcare operations such as quality assessments and physician certifications.

I have received, read and understand you Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and I can contact Mountain Bay Dental at any time to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

Patient Name

Relationship to Patient

Self

Spouse

Parent

Guardian

Patient/Parent/Guardian Signature

Date

AUTHORIZATION TO RELEASE INFORMATION

Purpose: This is to obtain authorization to release information regarding yourself covered under the Privacy Act to people other than yourself

I, authorize the following person(s) to have access to information covered under the Privacy Practice regarding myself.

(patient/parent/guardian please print name)

*NOTE: We cannot speak to your family about your treatment, pain, financials or even give appointment times to others at your request unless their name appears on this form.

Add Person

BELOW IS 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:

Individual refused to sign

Communication barriers prohibited the acknowledgement.

An Emergency situation prevented us from obtaining acknowledgement

Other

If other, please specify.

APPOINTMENT CANCELATION POLICY

At Mountain Bay Dental, we understand that unexpected situations may come up that would require you to cancel or change a scheduled appointment. In the event that you would need to cancel or change a scheduled appointment, we ask that you contact our office at least 24-48 hours prior to your scheduled appointment time. If you are calling us after hours or you get our voicemail, please leave a detailed message stating your need to change or cancel your scheduled appointment. This advance notice will allow us to better serve our patients. We have patients that have daily emergencies and or are on a wait list to be seen sooner. Proper notification of an opening in our schedule allows our other patients the opportunity to arrange their schedule and come to an earlier appointment. Failure to appear for your scheduled appointment without prior notification will be considered a “no-show”. Repeated “no-show” instances will result in termination from our practice.

In an effort to help our patients remember their appointments, Mountain Bay Dental will: Provide phone call reminders two business days in advance of your scheduled appointment. If we do not receive an appointment confirmation with our first attempt a second phone call will go out one business day prior to your appointment. Should you prefer an email or text confirmation and we have your information on file we can provide confirmation via email or text.

Patient or patients’ Guardian is responsible for having up to date and accurate contact information on file at all times. Should a patient’s information change we ask you to immediately update the information if the patient already has a scheduled appointment.

I have read and understand the above appointment cancelation policy.

Patient/Guardian

Date

I would like to have a copy of this policy for my records

Y N

Copy made and given to patient by

Employee Name

Your information will be encrypted.