New Patient Form

WELCOME

We would like to welcome you to Meister Dental Group. Our goal is to make everyone's visit pleasant and educational. We strive to teach exceptional oral care that will enable you to have a beautiful smile that lasts a lifetime.

Patient Information

Last Name

First Name

Middle Name

Today's Date

Birthdate

Age

SS #

Address

Home #

Work #

Cell #

Extension #

How did you hear about our practice?

In case of emergency:

Emergency Contact Name

Emergency Contact Phone #

Employment Information

Employer Name

Occupation

Work Address

Primary Dental Insurance

Insurance Company Name

Insurance Company Address

Insurance Company Phone

Plan Name

Group #

Policy Owner’s Name

Relationship to Patient

Policy Owner’s Birthdate

SS #

Policy Owner’s Employer

Employee’s Address

Secondary Dental Insurance

Insurance Company Name

Insurance Company Address

Insurance Company Phone

Plan Name

Group #

Policy Owner’s Name

Relationship to Patient

Policy Owner’s Birthdate

SS #

Policy Owner’s Employer

Employee’s Address

Dental History

Purpose of today’s visit

Date of last cleaning

Date of last X-Rays

How often do you brush?

Any:

Sensitive Teeth

Loose Teeth

Broken Teeth

Jaw Pain

Injuries to Teeth

Bleeding Gums

Have you had unpleasant dental experiences in the past?

Yes No

Explain:

Have you ever had:

Veneers

Root Canals

Oral Surgery

Crowns

Implants

Gum Treatment

Orthodontic Treatment

Have you ever done teeth whitening?

Yes No

Please Select

In Office

Overnight

Purchased

Are you interested in replacing any missing teeth?

Yes No

Which method:

With Dentures Bridges Implants

Do you have any questions for the dentist?

Yes No

Explain:

Medical History

Physician Name:

Office Address:

Telephone #

Are you currently under the care of a physician?

Yes No

Explain

Has there been a recent change in your health?

Yes No

Explain

Are you currently taking any prescription, over the counter or recreational drugs?

Yes No

Please List

Have you been hospitalized or had a serious illness within the past five years?

Yes No

Explain

Have you been treated now or in past with Bisphosphonates for Osteoporosis or cancer?

Yes No

Explain

Are you pregnant or is it likely that you could be pregnant at this time?

Yes No

If so, how far along?

Do you take blood thinners?

Yes No

If so, Type:

Do you smoke?

Yes No

Packs per day?

How long?

Do you chew Tobacco

Yes No

Select Yes/No if you have or ever had:

Artificial Limb/Joint/Hip

Yes No

When?

Artificial Heart Valve

Yes No

Acid Reflux

Yes No

Arthritis

Yes No

Anemia

Yes No

Asthma

Yes No

Angina

Yes No

Addictions

Yes No

Type:

Blood Disorder

Yes No

Type:

Aspirin Daily

Yes No

Bells Palsy

Yes No

Cancer

Yes No

Type:

Chronic Diarrhea

Yes No

Dizziness/Fainting

Yes No

Diabetes

Yes No

Type:

Type I Type II

Epilepsy/Seizures

Yes No

Emphysema

Yes No

Frequent Urination

Yes No

Glaucoma

Yes No

High Blood Pressure

Yes No

Hay Fever

Yes No

Head Injury

Yes No

Heart Murmur

Yes No

High Cholesterol

Yes No

Hyperthyroidism

Yes No

Hypothyroidism

Yes No

Hepatitis:

A B C

Heart Disease

Yes No

Explain:

Joint Surgery

Yes No

Kidney Problems

Yes No

Low Blood Pressure

Yes No

Migraines

Yes No

Mitral Valve Prolapse

Yes No

Mouth Ulcers

Yes No

Organ Transplant

Yes No

Prolonged Bleeding

Yes No

Psychiatric Care

Yes No

Pacemaker

Yes No

Rheumatic Fever

Yes No

Radiation Therapy

Yes No

Recurrent Infections

Yes No

Sinus Problems

Yes No

Stroke / TIA

Yes No

Date

STD

Yes No

Type:

Shortness of Breath

Yes No

Treated for AIDS/HIV

Yes No

Tuberculosis

Yes No

Trigeminal Neuralgia

Yes No

Ulcers/Colitis

Yes No

Unexplained Weight Loss

Yes No

If Other, please specifiy:

I authorize the doctor to perform all recommended treatment agreed upon by me and to use the appropriate medication and therapy for such treatment in connection with [Enter Patient Name below]. I understand that using anesthetic agents embodies a certain risk. Furthermore, I authorize and give consent to the doctor to use and employ such assistance as deemed to provide recommended treatment.

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

Patient or Responsible Party Signature

Date

Dentist Signature

Date

Financial Policy

Thank you for choosing our practice to serve your dental needs. Please take the time to read the following, initial each section, and sign and date the bottom of this form.

Full co-payment is due at the time of service unless arrangements have been made prior to the start of any treatment.

Insurance balances are ultimately the patient’s obligation. We will file most primary insurances at no cost to you as a courtesy. However, insurance balances which are not paid within 60 days may be billed to you. Please keep your walk-out statements and follow up with your insurance carrier to ensure prompt payment.

Some of your treatment may not be covered by your insurance carrier. The cost for such charges will be your responsibility.

At Meister Dental Group we schedule your appointment so that the time is reserved for you. We do not double book our patients; therefore, we reserve the right to charge $50.00 per broken appointment without the required notice of cancellation. This fee will be charged to compensate for the amount of time the doctor has spent in planning your treatment and the amount of time allotted for your appointment.

If your appointment must be rescheduled or canceled, we require that you notify us 24 hours before your scheduled appointment. Please notice that each case is different and that the required amount of time may vary. Patients are asked to confirm their appointments at least 48 hours in advance by directly contacting our office or by responding to our confirmation contact.

There will be a fee of $30.00 for any checks returned as Non-Sufficient Funds (NSF)

**Patient balances that go unpaid for 30 days or more may incur one or more of the following charges. Interest charges of 1.5% per month 18% APR collections fees (up to 25% of the full balance) Legal fees for collection services

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

Signature of Patient or Guardian

Name

Date

Your information will be encrypted.