New Patient Forms

Medical and Personal History

Last Name

First Name

Address

City

State

Zip

Home Phone

Work Phone

Cell Phone

SSN

Nickname

Employer

Date of Birth

Email address

General Dentist

Insurance

Add Secondary Insurance

Is this tooth problem due to an accident?

Yes No

If yes, describe the accident and the date it happened

In the following questions, check the box if applicable. Your answers are for our records only and will be considered confidential.

1. Has there been any change in your general health within the past year?

Yes No

2. Are you now under the care of a physician?

Yes No

If so, what is the condition being treated?

3. Have you had any serious illness or operation?

Yes No

If so, what was the illness or operation?

B. Do you have cancer?

If so, are you currently being treated?

If other, Please specify

5. Have you had abnormal bleeding associated with previous extractions. surgery,or trauma?

Yes No

A. Do you bruise easily?

Yes No

B. Have you ever required a blood transfusion?

Yes No

If so, explain the circumstances

6. Do you have any blood disorder such as anemia?

Yes No

7. Are you taking any drug or medicine?

Yes No

If others, Please specify

8. Are you allergic or have you experienced intolerance to:

Local anesthetics ("Novocaine")

Penicillin or other antibiotics

Sulfa drugs

Barbiturates, sedatives, or sleeping pills

Aspirin

Latex

Codeine

Other

None

If others, Please specify

9. Do you have any disease, condition, or problem not listed above that you think I should know about?

Yes No

If so, please explain

Women

10. Are you pregnant?

Yes No

11. Are you taking birth control pills?

Yes No

If so, be aware antibiotics can reduce effectiveness or cause possible failure of oral contraceptives. Please check

Med Alert

Drug Allergies

Antibio Premed

Latex Allergy

None

To the best of my knowledge, the information provided to this office is complete and accurate. I acknowledge that ALL charges incurred in this office are my responsibility. Should my insurance, for any reason, fail to pay for all the charges billed, I agree to pay for the services upon notification by a representative of this office. I understand that if my account remains unpaid by me for a period of 30 days, it may be referred to an attorney or collection agency for collection and that I further agree to be responsible and pay for all the costs incurred, including up to 33.3% attorney or collection agency fees (minimum of $50.00) and interest at 1.5% per month (18% per annum).

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.

Print Name

Date:

HIPAA Policy

I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), 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 that treatment directly and indirectly.
Obtain payment from third-party payers.
Conduct normal healthcare operations such as quality assessments and physician certifications.

I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address below 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 options. 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.

I understand that I may revoke this consent in writing at any time, except the extent that you have taken action relying on this consent.

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 Name / Signature

Date

Relationship to Patient (Parent, Guardian, or Self)

Office Policy

Our office is committed to meeting and exceeding the standard of dental care. Any charges you incur are your responsibility regardless of your insurance coverage. We must emphasize that our relationship is with you, our patient, not with your insurance company. Your insurance policy is a contract between you, your employer, and your insurance company. As a courtesy to you, we will process your insurance claim from our office for primary and secondary claims only.

Your estimated co-payment for treatment, which is the amount not covered by your insurance, is due at the time services are rendered. Your co-payment may be adjusted after the time of service depending upon the final reconciliation of your insurance payment/explanation of benefits. Please note that any balance remaining after insurance payments is your responsibility, and is due to the provider.

Our office accepts Cash, Check, MasterCard, Visa, Discover, American Express, Apple Pay and Care Credit.

Please note that if your account remains unpaid for a period of 30 days, interest at 1.5% will be applied per month. In the event that we refer your account to an attorney or collection agency, you may be subject to collection fees as well.

We require a 48-hour notice for any canceled or rescheduled appointments. Failure to comply with this notice will result in a failed appointment fee of up to $150.

Please do not hesitate to ask if you have any questions regarding this financial agreement or need a copy for your records. We are committed to providing you with the most positive experience in dental care.

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 Name / Signature

Relationship to patient

Date

Your information will be encrypted.