New Patient Information

Appointment Date

Appointment Time

Patient's Name

Address

City

State

Zip

Date of Birth

Social Security Number

Employer

Home Phone

Work Phone

Cell Phone

Other

Email address

Spouse's Name

Who may we thank for your referral?

Last Dental Check up

Do you have a current set of X-Ray?

Name of previous dentist (If applicable)

INSURANCE INFORMATION

Insurance Carrier

Insurance Subscriber

Insurance Employer

Date of Birth (Subscriber)

Subscriber ID #

Group #

MEDICAL AND DENTAL HISTORY

Last Name

First Name

Preferred Name

Emergency Contact

(Must list at least one)

Within the past year, have there been any changes in your general health?

Yes No

What is your Primary Care Physicians name & phone number? What is the date (or approximate date) of your last medical exam?

Name

Phone Number

Date

Are you currently under the care of a physician due to a specific condition?

Yes No

Have you ever been hospitalized within the last 5 years due to a surgery or illness?

Yes No

If any of the previous questions are marked, please explain

WOMEN ONLY

Are you currently pregnant?

Yes No

What MEDICATIONS or other substances are you taking or have you taken in the past 2 months?

Please list all PRESCRIPTION and NON-PRESCRIPTION drugs inclusing aspirin, birth control pills, herbal medication or other supplements. Write "none" if you are not taking any medications or substances.

Have you taken or are you taking drugs to control bone loss? (i.e. Fosomax)

Yes No

Sleep Apnea

Snore

Use CPAP Machine

Other

Do you use Nicotine or Marijuana?

Cigarettes

E-Cigarettes

Vaping

Cigar/Pipe

Chewing Tobacco

Marijuana (Recreational)

Marijuana (Medicinal)

Other

If other, please specify.

Please indicate if you have experienced any of the following:

Breathing Problems?

Asthma

Emphysema

COPD

Tuberculosis

Shortness of breath

Other head and neck problems - explain

Hormone or Gland Problems?

Thyroid disease

(Hyperthyroidism, Hypothyroidism)

Adrenal or pancreatic disease

Diabetes

Other hormone or gland problems - explain

Muscle, Bone, or Skin Problems?

Artificial joint replacement

Arthritis

Skin cancer

Pre-Medication - for artificial joint replacement

Osteoporosis

Back problems

Other muscle, bone, or skin problems - explain

Stomach, Liver, Intestinal Problems?

Liver disease

Hepatitis

Acid Reflux (GERD)

Ulcers

Other stomach, liver, intestinal problems - explain

Allergic Reactions or Other Problems?

Seasonal allergies

Penicillin

Erythromycin

Codeine

Local anesthetics

Food/flavoring

Sulfa

Other substances - explain

Other problems with the blood or auto immune system - explain

What is the reason for your dental visit today?

When was your last visit to the dentist (if to a different office)? Who did you go to?

Please list any other parties who can have access to your health information: (This includes step-parents, grandparents and any other care takers who cen have access to this patient's health information):

Add Additional Name

To the best of my knowledge, all of the preceding information is true and correct. If I ever have a change in my health, I will inform the office at my next dental appointment without fail.

Authorization

I hereby certify that I have read and understand the previous information and that it is accurate and true to the best of my knowledge. I acknowledge that providing incorrect and/or inaccurate information has the potential of being hazardous to my health.

I authorize the diagnosis of my dental health by means of radiographs, study models, photographs, or other diagnostic aids deemed appropriate.

I have had the opportunity to review the HIPPA policy for this office. I authorize the dentist to release any information including the diagnosis and records of treatment or examination for myself and my dependent(s) to third-party insurance carriers, payors, and/or healthcare practitioners. I authorize the payment from my insurance carrier to submit payment directly to the dentist or dental practice to be applied directly to any outstanding balance on my account.

I understand that I am financially responsible for any outstanding balance for services provided that are not fully covered by insurance, and payment is due on the day services are rendered. I consent and agree to be financially responsible for payment of all services rendered on my behalf or on behalf of my dependents (if any).

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.

Signature of Patient / Parent or Guardian

Date

Relationship to Patient

WE SET ASIDE 90 MINUTES FOR OUR NEW PATIENT EXAMS, WE TAKE X-RAYS, PICTURES, DO AN ORAL CANCER SCREENING, PERIO CHART, AND COME UP WITH A CUSTOMIZED TREATMENT PLAN TO FIT YOUR DENTAL NEEDS.

PLEASE PLAN TO BE HERE FOR UP TO 2 HOURS. THIS ALLOWS DOCTOR AND TEAM ENOUGH TIME TO EVALUATE YOUR INDIVIDUAL ORAL HEALTH. THEN WE CAN SCHEDULE YOUR CLEANING AND ANY DENTAL WORK THAT MAY BE RECOMMENDED BY DR. SANFORD.

CANCELLATION AND NO SHOW POLICY REMINDER

Here at Dr. Susanne M. Sanford, D.D.S., we take pride in our commitment to providing quality care and patient satisfaction.

This letter is a reminder that as our patient, you have a responsibility to notify us in a timely manner (2 business days) of your need to cancel/ reschedule an appointment. This timely information allows us to reschedule other patients who are waiting to see the doctor.

We understand emergencies and sudden illnesses do occur which we will accommodate on a case by case basis. However if this seems to be a chronic occurrence, we reserve the right to charge a short notice/ no show fee of $50.00, or possible dismissal from the practice.

We feel privileged to be your dental provider and thank you for your understanding in this manner.

Sincerely,
Dr. Susanne M. Sanford D.D.S

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