New Patient Forms

Thank you for selecting our dental healthcare team! We will strive to provide you with the best possible dental care. To help us meet all your dental healthcare needs, please fill out this form completely in ink. If you have any questions or need assistance, please ask us - we will be happy to help.

Patient Information (CONFIDENTIAL)

SS#/SIN

Date

Name

Birthdate

Age

Home Phone

Address

City

State/Prov.

ZIP/P.C.

Cell Phone

Check Appropriate Status

Minor Single Married Divorced Widowed Separated

If Student, Name of School/College

City

State/Province

Full Time Part Time

Patient or Parent/Guardian’s Employer

Work Phone

Business Address

City

State/Prov.

ZIP/P.C.

Spouse or Parent/Guardian’s Name

Employer

Work Phone

Whom may we thank for referring vou?

Person to contact in case of emergency

Phone

Responsible Party

Name of Person Responsible for this Account

Relationship to Patient

Address

City

State/Prov.

Zip/P.C.

Home Phone

Cell Phone

Driver's License #

Birthdate

Financial Institution

Employer

Work Phone

SS#/SIN

Is this person currently a patient in our office?

Yes No

For your convenience, we offer the following methods of payment. Please check the option you prefer. Payment in full at each appointment.

Cash

Personal Check

Credit Card

If Credit Card, please specify

Visa

Mastercard

Discover

I wish to discuss the office’s payment policy

Dental Insurance Information

Name of Insured

Relationship to Patient

Birthdate

SS#/SIN

Date Employed

Name of Employer

Work Phone

Address of Employer

City

State/Prov.

Zip/P.C.

Insurance Company

Group#

Policy/ID#

Ins. Co. Address

City

State/Prov.

Zip/P.C.

How much is your deductible?

How much have you used?

Max. annual benefit

DO YOU HAVE ANY ADDITIONAL INSURANCE?

YES NO

IF YES, COMPLETE THE FOLLOWING:

Name of Insured

Relationship to Patient

Birthdate

SS#/SIN

Date Employed

Name of Employer

Work Phone

Address of Employer

City

State/Prov.

Zip/P.C.

Insurance Company

Group#

Policy/ID#

Ins. Co. Address

City

State/Prov.

Zip/P.C.

How much is your deductible?

How much have you used?

Max. annual benefit

Patient Medical History

Physician

Office Phone

Date of Last Exam

1. Are you under medical treatment now?

Yes No

2. Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years?

Yes No

If yes, please explain

3. Are you taking any medication(s) including non-prescription medicine?

Yes No

If yes, what medication(s) are you taking?

4. Have you ever taken Fosamax, Boniva, Actonel or any cancer medications containing bisphosphonates?

Yes No

5. Do you use tobacco?

Yes No

6. Do you use controlled substances?

Yes No

7. Do you have or have you had any of the following?

High Blood Pressure

Yes No

Heart Disease

Yes No

Chest Pains

Yes No

Heart Attack

Yes No

Cardiac Pacemaker

Yes No

Easily Winded

Yes No

Rheumatic Fever

Yes No

Heart Murmur

Yes No

Stroke

Yes No

Swollen Ankles

Yes No

Angina

Yes No

Hay Fever / Allergies

Yes No

Fainting / Seizures

Yes No

Frequently Tired

Yes No

Tuberculosis

Yes No

Asthma

Yes No

Anemia

Yes No

Radiation Therapy

Yes No

Low Blood Pressure

Yes No

Emphysema

Yes No

Glaucoma

Yes No

Epilepsy / Convulsions

Yes No

Cancer

Yes No

Recent Weight Loss

Yes No

Leukemia

Yes No

Arthritis

Yes No

Liver Disease

Yes No

Diabetes

Yes No

Joint Replacement or Implant

Yes No

Heart Trouble

Yes No

Kidney Diseases

Yes No

Hepatitis / Jaundice

Yes No

Respiratory Problems

Yes No

AIDS or HIV Infection

Yes No

Sexually Transmitted Disease

Yes No

Mitral Valve Prolapse

Yes No

Thyroid Problem

Yes No

Stomach Troubles / Ulcers

Yes No

Acid Reflux

Yes No

Osteoporosis

Yes No

Other

8. Are you allergic to or have you had any reactions to the following?

Local Anesthetics (e.g. Novocain)

Yes No

Penicillin or any other Antibiotics

Yes No

Sulfa Drugs

Yes No

Codeine

Yes No

Barbiturates

Yes No

Sedatives

Yes No

Iodine

Yes No

Aspirin

Yes No

Any Metals (e.g. nickel, mercury, etc.)

Yes No

Latex Rubber

Yes No

Other (please list)

9. Do you have a persistent cough or throat clearing not associated with a known illness (lasting more than 3 weeks)?

Yes No

10. Women Only

a.) Are you pregnant or think you may be pregnant?

Yes No

b.) Are you nursing?

Yes No

b.) Are you taking oral contraceptives?

Yes No

Patient Dental History

Name of Previous Dentist

Location of Previous Dentist

Date of Last Exam

1. Do your gums bleed while brushing or flossing?

Yes No

2. Are your teeth sensitive to hot or cold liquids/foods?

Yes No

3. Are your teeth sensitive to sweet or sour liquids/foods?

Yes No

4. Do you feel pain to any of your teeth?

Yes No

5. Do you have any sores or lumps in or near your mouth?

Yes No

6. Have you had any head, neck or jaw injuries?

Yes No

7. Have you ever experienced any of the following problems in your jaw?

Clicking

Yes No

Pain (joint, ear, side of face)

Yes No

Difficulty in opening or closing

Yes No

Difficulty in chewing

Yes No

8. Do you have frequent headaches?

Yes No

9. Do you clench or grind your teeth?

Yes No

10. Do you bite your lips or cheeks frequently?

Yes No

11. Have you ever had any difficult extractions in the past?

Yes No

12. Have you ever had any prolonged bleeding following extractions?

Yes No

13. Have you had any orthodontic treatment?

Yes No

14. Do you wear dentures or partials?

Yes No

If yes, date of placement

15. Have you ever received oral hygiene instructions regarding the care of your teeth and gums?

Yes No

16. Do you like your smile?

Yes No

Authorization and Release

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such Dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

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 (or parent/guardian if minor)

Date

Doctor's Comments

Signature

Date

HIPAA Consent

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, but is not mandatory for me to sign in order 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 and your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given a copy of your 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 above 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.

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

Digital Photography

Dr. Falkenheiner may take digital photographs to better explain certain aspects of your existing dental health or planned treatment to you. We request your permission to show these photographs to better explain treatment options to other patients (as you will be shown photos for the same reason). Your identity will not be shared.

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, Parent or Guardian Signature

Date

Patient Name

Written Financial Policy

Thank you for choosing Dr. S. Lee Falkenheiner. Our primary mission is to deliver the best and most comprehensive dental care available. An important part of the mission is making the cost of optimal care as easy and manageable for our patients as possible by offering several payment options.

Payment Options:

You can choose from:

Cash, Check, Visa or Mastercard
NO INTEREST(1) Payment Plans(2) from CareCredit
- Allow you to pay over time with NO INTEREST(1)
- Convenient, low monthly payment plans(2) also available
- No annual fees or pre-payment penalties

Please note:

Dr. S. Lee Falkenheiner requires full payment at the completion of your treatment.

We accept payment in halves. For plans requiring more than 2 appointments, alternative payment arrangements may be provided.

We also offer in-house financing for up to 3 months. No interest

For patients with dental insurance, we are happy to work with your carrier to maximize your benefit and directly bill them for reimbursement for your treatment.(3)

A fee of $25 is charged for patients who miss or cancel more than 3 times in a calendar year without 24-hour notice.

NSF fee is $30 for returned checks.

For patients who receive direct payment from your insurance company, you are required to leave a check in the amount of the insurance payment. The check will be returned to you when the insurance check is received.

(patient initials)

If you have any questions, please do not hesitate to ask. We are here to help you get the dentistry you want or need.

Patient, Parent or Guardian Signature

Date

Patient Name

(1) If paid within the promotional period. Otherwise, interest assessed from purchase date. Minimum monthly payment required.

(2) Subject to credit approval

(3) However if we do not receive payment from your insurance carrier within 60 days, you will be responsible for payment of your treatment fees and collection of your benefits directly from your insurance carrier.

Your information will be encrypted.