New Patient Forms

Health History Form

Email:

Today's Date:

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

First Name:

Last Name:

Middle:

Home Phone: include area code

Business/Cell Phone: Include area code

Address:

City:

State:

Zip:

Occupation:

Height:

Weight:

Date of birth:

Sex:

M F

SS # or Patient ID:

Emergency Contact:

Relationship:

Home Phone:

Cell Phone:

If you are completing this form for another person, what is your relationship to that person?

Your Name:

Relationship:

Do you have any of the following diseases or problems: (Check DK if you Don’t Know the answer to the questio

Active Tuberculosis

Yes No DK

Persistent cough greater than a 3 week duration

Yes No DK

Cough that produces blood

Yes No DK

Been exposed to anyone with tuberculosis .

Yes No DK

If you answer yes to any of the 4 items above, please stop and return this form to the receptionist.

Dental Information

For the following questions, please select your responses to the following questions.

Do your gums bleed when you brush or floss?

Yes No DK

Are your teeth sensitive to cold, hot, sweets or pressure?

Yes No DK

Does food or floss catch between your teeth?

Yes No DK

Is your mouth dry?

Yes No DK

Have you had any periodontal (gum) treatments?

Yes No DK

Have you ever had orthodontic (braces) treatment?

Yes No DK

Have you had any problems associated with previous dental treatment?

Yes No DK

Is your home water supply fluoridated?

Yes No DK

Do you drink bottled or filtered water?

Yes No DK

If yes, how often?

DAILY WEEKLY OCCASIONALLY

Are you currently experiencing dental pain or discomfort?

Yes No DK

Do you have earaches or neck pains?

Yes No DK

Do you have any clicking, popping or discomfort in the jaw?

Yes No DK

Do you brux or grind your teeth?

Yes No DK

Do you have sores or ulcers in your mouth?

Yes No DK

Do you wear dentures or partials?

Yes No DK

Do you participate in active recreational activities?

Yes No DK

Have you ever had a serious injury to your head or mouth?

Yes No DK

Date of your last dental exam:

What was done at that time?:

Date of last dental x-rays:

What is the reason for your dental visit today?

How do you feel about your smile

Medical Information

Please select your response to indicate if you have or have not had any of the following diseases or problems. (Check DK if you Don’t Know the answer to the question)

Are you now under the care of a physician?

Yes No DK

Physician Name:

Phone: Include area code

Address:

City:

State:

Zip:

Are you in good health?

Yes No DK

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

Yes No DK

If yes, what condition is being treated?

Date of last physical exam

Have you had a serious illness, operation or been hospitalized in the past 5 years?

Yes No DK

If yes, what was the illness or problem?

Are you taking or have you recently taken any prescription or over the counter medicines?

Yes No DK

If so, please list all, including vitamins, natural or herbal preparations and/or diet supplements:

Add medication

Medical Information

Please select your response to indicate if you have or have not had any of the following diseases or problems. (Check DK if you Don’t Know the answer to the question)

Do you wear contact lenses?

Yes No DK

Joint Replacement

Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement?

Yes No DK

Date

If yes, have you had any complications?

Are you taking or scheduled to begin taking either of the medications, alendronate (Fosamax) or risedronate (Actonel) for osteoporosis or Paget’s disease?

Yes No DK

Since 2001, were you treated or are you presently scheduled to begin treatment with the intravenous bisphosphonates (Aredia or Zometa) for bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease, multiple myeloma or metastatic cancer?

Yes No DK

Date Treatment began:

Do you use controlled substances

Yes No DK

Do you use tobacco (smoking, snuff, chew, bidis)?

Yes No DK

If so, how interested are you in stopping?

VERY SOMEWHAT NOT INTERESTED

Do you drink alcoholic beverages?

Yes No DK

If yes, how much alcohol did you drink in the last 24 hours?

If yes, how much do you typically drink in a week?

WOMEN ONLY Are you:

Pregnant?

Yes No DK

Taking birth control pills or hormonal replacement?

Yes No DK

Nursing?

Yes No DK

If pregnant, please provide number of weeks:

Due Date:

Allergies

Are you allergic to or have you had a reaction to: To all yes responses, specify type of reaction.

Local anesthetics

Yes No DK

Reaction:

Aspirin

Yes No DK

Reaction:

Penicillin or other antibiotics

Yes No DK

Reaction:

Barbiturates, sedatives or sleeping pills

Yes No DK

Reaction:

Sulfa drugs

Yes No DK

Reaction:

Codeine or other narcotics

Yes No DK

Reaction:

Metals

Yes No DK

Reaction:

Latex (rubber)

Yes No DK

Reaction:

Iodine

Yes No DK

Reaction:

Hay fever/seasona

Yes No DK

Reaction:

Animals

Yes No DK

Reaction:

Food

Yes No DK

Reaction:

Other

Yes No DK

Please specify:

Reaction:

Please select your response to indicate if you have or have not had any of the following diseases or problems.

Previous infective endocarditis

Yes No DK

Artificial (prothetic) heart valve

Yes No DK

Damaged valves in transplanted hear

Yes No DK

Congenital heart disease (CHD)

Unrepaired, cyanotic CHD

Yes No DK

Repaired (completely) in last 6 months

Yes No DK

Repaired CHD with residual defects

Yes No DK

Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD.

Cardiovascular disease

Yes No DK

Angina

Yes No DK

Arteriosclerosis

Yes No DK

Congestive heart failure

Yes No DK

Damaged heart valves

Yes No DK

Heart Attack

Yes No DK

Heart murmur

Yes No DK

Low blood pressure

Yes No DK

High blood pressure

Yes No DK

Other congenital heart defects

Yes No DK

Mitral valve prolapse

Yes No DK

Pacemaker

Yes No DK

Rheumatic heart disease

Yes No DK

Abnormal bleeding

Yes No DK

Anemia

Yes No DK

Blood transfusion

Yes No DK

If yes, date:

Hemophilia

Yes No DK

AIDS or HIV infection

Yes No DK

Arthritis

Yes No DK

Autoimmune disease

Yes No DK

Rheumatoid arthritis

Yes No DK

Systemic lupus erythematosus

Yes No DK

Asthma

Yes No DK

Bronchitis

Yes No DK

Emphysema

Yes No DK

Sinus trouble

Yes No DK

Tuberculosis

Yes No DK

Cancer/Chemotherapy/Radiation Treatment

Yes No DK

Chest pain upon exertion

Yes No DK

Chronic pain

Yes No DK

Diabetes Type I or II

Yes No DK

Eating disorder

Yes No DK

Malnutrition

Yes No DK

Gastrointestinal disease

Yes No DK

G.E. Reflux/persistent heartburn

Yes No DK

Ulcers

Yes No DK

Thyroid problems

Yes No DK

Stroke

Yes No DK

Glaucoma

Yes No DK

Hepatitis, jaundice or liver disease

Yes No DK

Epilepsy

Yes No DK

Fainting Spells or Seizures

Yes No DK

Neurological disorders

Yes No DK

If yes, specify:

Sleep disorder

Yes No DK

Mental health disorders

Yes No DK

If yes, please specify:

Recurring infections

Yes No DK

Type of infections

Kidney problems

Yes No DK

Night sweats

Yes No DK

Osteoporosis

Yes No DK

Persistent swollen glands in neck

Yes No DK

Severe headaches/migraines

Yes No DK

Severe or rapid weight loss

Yes No DK

Sexually transmitted disease

Yes No DK

Excessive urination

Yes No DK

Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?

Yes No

Name of physician or dentist making recommendation:

Phone:

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

Yes No

Please explain:

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

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/Legal Guardian:

Date:

FOR COMPLETION BY DENTIST

Comments:

FINANCIAL POLICY

Thank you for choosing our office to provide your dental care. We appreciate your trust and look forward to working with you. In order to prevent any misunderstanding and to better serve you, we ask that all patients read and sign our FINANCIAL POLICY. If you have any questions, please ask the front desk.

VERIFYING INSURANCE: As a courtesy to you, we will verify your insurance for eligibility benefits prior to your appointment as well as any time that you notify us of a change in your coverage. The insurance companies do not guarantee payment based on the information that they provide us. You are ultimately responsible for knowing if there are any waiting periods for work to be performed. Any amounts on your treatment plans that are not covered by your insurance, are your financial responsibility.
PAYMENT: Payment is due at the time of service. Additionally, if you have a balance following an insurance payment from a previous visit, you will be expected to pay that amount as well. Once treatment is rendered, no refunds will be issued.
INSURANCE INFORMATION: New insurance as well as changes in insurance must be provided to this office prior to an appointment. Failure to provide correct and current insurance information may result in the entire bill being your responsibility.
CHANGES IN PERSONAL INFORMATION: Changes in your address or telephone numbers should be kept current with our office. If this office is unable to contact you by telephone or mail and your balance is overdue, your account will be sent to a collection agency.
REQUESTS FOR ADDITIONAL INFORMATION: These must be responded to immediately. Such requests include proof of a college student’s full-time status and proof of continued enrollment in an insurance plan. Failure to provide this information to the insurance company in a timely manner may result in the entire balance being your responsibility.
PAYMENT PLANS: Please see our staff at the front desk for details.
BALANCES: If your account balance exceeds 30 days, your account will be subject to a $25-dollar late fee. If you do not pay your balance or arrange a payment plan, your account will be turned over to a collection agency. They collection agency will report any unpaid balance to the major credit bureaus.
RETURNED CHECKS: There will be a $30 fee for all returned checks. The amount of the check plus the fee must be paid within 10 days of notification by money order, cash or credit card. Once a check has been returned, this office will no longer accept personal checks for payment.
CANCELLATIONS/FAILED APPOINTMENTS: We request 48-hours notice if you are cancelling an appointment. There will be a $50 fee for cancellations made without 48 hours notice and for failed appointments (“no shows”). The $50 will be posted to your account, and you will not be allowed to make any other appointments for yourself or your family members until it is paid in full.

*** Thank you for reading this information in full. Please sign below to acknowledge your understanding of the entire FINANCIAL POLICY. ***

Patient or Guardian Signature:

Date:

Patient or Guardian Name:

Signature of Dentist:

Date:

Consent for Internet Communication

Patient Last Name:

First Name:

MI:

Preferred Name:

I grant my permission to the dental practice to upload and store confidential patient information (including account information, appointment information and clinical information) to the secured web site for the dental practice. I understand that, for security purposes, the site requires a user ID and password for access and use. I also understand the dental practice and I are responsible for maintaining the strict confidentiality of any ID and password assigned to me; and that the dental practice is not liable for any charges, damages, or losses that may be incurred or suffered as a result of my failure to maintain confidentiality. I understand the dental practice is not liable for any harm related to the theft of my ID and password, my disclosure of my ID and password, or my authorization to allow another person or entity to access and use the dental practice web site with my ID and password. I also agree to immediately notify the dental practice of any unauthorized use of my ID or any other need to deactivate my ID due to security concerns.

Appointment Policy

To better serve our patients we have implemented certain guidelines for appointment cancellations and confirmations:

Appointments: (Cleanings, exams, treatment etc.)

1. Initial

A confirmation phone call, email or text may be sent before your appointment. If no confirmation is received within 1 week of your appointment with the Hygienist or within 1 day of your appointment with the dentist your appointment may be subject to cancellation so that another patient can be accommodated.

2. Initial

Please call to report any changes of address, email or phone number. If we receive return mail or cannot reach you to confirm, your appointment may be subject to cancellation so that another patient can be accommodated.

3. Initial

Any cancellation with less than 24-hour notice is subject to a $50 cancellation fee. After the 2nd no-show, the appointment will need to be pre-paid. Any additional no-shows may result in patient dismissal from the practice.

Patient Name:

Parent or Guardian Signature:

Date:

Acknowledgement of Receipt of Notice of Privacy Policies (Adult)

I have received a copy of the Notice of Privacy Practices of Smile Avenue Family Dental. I hereby authorize, as indicated by my signature below, Smile Avenue Family Dental to use and to disclose my protected health information for any necessary clinical, financial, and insurance purpose, as authorized in the Patient Consent form.

Name:

Address:

City

State:

Zip:

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:

Date

Please check your preferred means of communication:

You may contact me at my home telephone number

You may contact me on my mobile telephone number

You may contact me on my work telephone number

You may send me an unencrypted email/text message at:

Please list authorized persons with whom we may discuss your Protected Health Information (PHI) inaddition to custodial parents and legal guardians:

Add authorized person(s)

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 obtaining the acknowledgement

An emergency situation prevented us from obtaining the acknowledgement

Other

If Other, please specify:

Staff Person Initials:

Acknowledgement of Receipt of Notice of Privacy Policies (Minor)

I have received a copy of the Notice of Privacy Practices for Smile Avenue Family Dental on behalf of my child

I hereby authorize, as indicated by my signature below, Smile Avenue Family Dental to use and to disclose my protected health information for any necessary clinical, financial, and insurance purpose, as authorized in the Patient Consent form.

Name:

Address:

City

State:

Zip:

Signature:

Date

Please check your preferred means of communication:

You may contact me at my home telephone number

You may contact me on my mobile telephone number

You may contact me on my work telephone number

You may send me an unencrypted email/text message at:

Please list authorized persons with whom we may discuss your Protected Health Information (PHI) inaddition to custodial parents and legal guardians:

Add authorized person(s)

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 obtaining the acknowledgement

An emergency situation prevented us from obtaining the acknowledgement

Other

If Other, please specify:

Staff Person Initials:

General Consent Form

Please read and sign the section at the bottom of the form.

Patient Name:

WORK TO BE DONE

I understand that I am having the following work done

photos

x-rays

exam

cleaning

fluoride

SEALANTS

I understand that I may receive sealants. Sealants are a protective coating material that is applied to the chewing surface of back molars to act as a protective barrier from acids and plaque. Sealants generally last for several years but occasionally require reapplication.

DRUGS AND MEDICATIONS

I understand that local anesthetics, antibiotics, pain medications, and other drugs can cause redness, swelling of tissues, pain, itching, vomiting, and/or anaphylactic shock (severe allergic reaction). I understand that not everyone reacts the same to medication and such reactions are not predictable.

CHANGES IN TREATMENT PLAN

I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during examination, the most common being root canal therapy following routine restorative procedures, a crown being required instead of a routine filling, and an extraction being required due to a non-restorable tooth with gross decay or fracture. If this is the case, proposed changes will be explained to me. Any differences in fee will be authorized by me before any changes take place.

FILLINGS

I understand that teeth can become or remain sensitive after having a filling placed. This can occur with either amalgam (silver) or composite (tooth colored) filling materials. Sensitivity may require additional treatment. Removal of deep decay can lead to an abscessed tooth requiring either a root canal or extraction. I understand that if I need additional treatment the cost is my responsibility.

I understand that dentistry is not an exact science and that reputable practitioners cannot guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the dental treatment which I have requested and authorized. I have had the opportunity to read this form and ask questions. All of my questions have been answered to my satisfaction. I consent to the proposed treatment.

Name of Patient:

Date

Name of Parent/Guardian (if patient is a minor):

Date

Name of Dentist:

Date

Name of Witness:

Date

COVID-19 Notice and Acknowledgement of Risk Form

Our goal is to provide a safe environment for our patients and staff, and to advance the safety of our local community. This document provides information we ask you to acknowledge and understand regarding the COVID-19 virus.

The COVID-19 virus is a serious and highly contagious disease. The World Health Organization has classified it as a pandemic. You could contract COVID-19 from a variety of sources. Our practice wants to ensure you are aware of the additional risks of contracting COVID-19 associated with dental care.

The COVID-19 virus has a long incubation period. You or your healthcare providers may have the virus and not show symptoms and yet still be highly contagious. Determining who is infected by COVID-19 is challenging and complicated due to limited availability for virus testing and possible spread by asymptomatic carriers.

Due to the frequency and timing of other dental patients, the characteristics of the virus, and the characteristics of dental procedures, there is an elevated risk of you contracting the virus simply by being in the dental office.

Dental procedures create water spray, which is one way the disease is spread. The ultra-fine nature of the water spray can linger in the air for a long time, allowing for transmission of the COVID-19 virus to those nearby.

You cannot wear a protective mask over your mouth during treatment as your providers need access to your mouth to render care. This leaves you vulnerable to COVID-19 transmission while receiving dental treatment.

I confirm that I have read the Notice above and understand and accept that there is an increased risk of contracting the COVID-19 virus in the dental office or with dental treatment. I understand and accept the additional risk of contracting COVID-19 from contact at this office. I also acknowledge that I could contract the COVID-19 virus from outside this office and unrelated to my visit here.

I have read and understands the information stated above:

Name:

Date:

Witness

Oral ID Form

Shine Light Save Lives
Consent Form-Oral Cancer Screening

Our office SMILE AVENUE FAMILY DENTAL, strives to bring its patients state-of-the-art technology to provide you with the latest advancements in oral health. We have recently introduced the OralID screening device into our office. The OralID examination will allow us to visualize any oral mucosal abnormalities including cancer and dysplasia (pre-cancer) before they can be detected with the naked eye. The procedure is quick, painless and no rinses or dyes are used.

Similar to other cancers, early detection of Oral Cancer is critical. Studies have shown that early detection of oral cancer with technologies like the OralID dramatically improves the survivability of the disease. If oral cancer is detected in its later stages, which typically occurs during a conventional oral cancer exam, the chances of survival are dramatically reduced.

Who is at Risk?

People age-17+ years
Tobacco users
Alcohol users
People with HPV infection

If you have any questions about risk factors, please feel free to talk to our hygiene staff. We screen all of our patients with the OralID to reduce the mortality of late stage detection.

Our office charges $25 per screening with the OralID. We will attempt to bill your insurance, but you will be responsible for any unpaid amount or denial by your insurance company.

Signature:

Date

Your information will be encrypted.

New Patient Forms

Health History Form

Dental Information

Medical Information

Medical Information

Joint Replacement

Allergies

FINANCIAL POLICY

Consent for Internet Communication

Appointment Policy

Appointments: (Cleanings, exams, treatment etc.)

Acknowledgement of Receipt of Notice of Privacy Policies (Adult)

Please check your preferred means of communication:

Acknowledgement of Receipt of Notice of Privacy Policies (Minor)

Please check your preferred means of communication:

General Consent Form

COVID-19 Notice and Acknowledgement of Risk Form

Oral ID Form

Shine Light Save LivesConsent Form-Oral Cancer Screening

Shine Light Save Lives
Consent Form-Oral Cancer Screening