New Patient Paperwork

Patient Information

First Name

Last Name

SSN

Birth Date

Mailing Address

City

State

Zip

Cell Phone

Home Phone

Check appropriate box

Single

Married

Divorced

Widowed

Separated

Spouse Name

Patient's Employer

Work Phone

Occupation

Business Address

City

State

Zip

Whom may we thank for referring you?

Responsible Party

Name of Person Responsible for this Account

Relationship to Patient

Address

City

State

Zip

Home Phone

Cell Phone

Work Phone

Is this person currently a patient at our office?

Yes No

Insurance Information

Name of Insured

SSN

Relationship to Patient

Name of Employer

Birth Date

Address of Employer

City

State

Zip

Insurance Company

Group #

Policy/Subscriber ID #

Insurance Co. Address

City

State

Zip

Do you have any additional insurance?

Yes No

If yes, complete the following.

Name of Insured

Relationship to Patient

Name of Employer

Birth Date

Address of Employer

City

State

Zip

Insurance Company

Group #

Policy/Subscriber ID #

Insurance Co. 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

Medical Information

Name

Date

Personal Care Physician (PCP) Name

Personal Care Physician (PCP) Address

City

State

Zip

1. Have you had any major surgeries, or have been hospitalized within the last 5 years?

Yes No

If yes, for what?

2. Have you ever been required to take any medications prior to any dental treatments?

Yes No

If yes, name of medication and for what?

3. Are you currently being treated by a physician?

Yes No

If yes, for what?

4. Are you currently taking any medications?

Yes No

If yes, name of medication(s) and for what?

5. Are you allergic to any drugs?

Yes No

If yes, please list?

6. Have you ever received counseling for excessive use of alcohol and/or prescription drugs?

Yes No

7. Have you ever had a skin rash or other reaction to metal jewelry, or any other metals?

Yes No

If yes, what type of metal(s)?

8. Do you smoke?

Yes No

If yes, what and how often?

9. Do you bleed excessively upon injury?

Yes No

10. Are you pregnant?

Yes No

If yes, when is your due date?

11. Have you ever been involved with any dental/medical legal activity?

Yes No

Medical Conditions

** If you checked either I or T, please describe the condition:

Emergency Contact

Person to be contacted in case of an emergency

Name

Relationship to Patient

Address

Home Phone

Cell Phone

Work Phone

Signature

Date

Reviewed By

Date

Dental History

Name

Date

1. What is the purpose of your initial visit?

2. When your last dental visit, and what was done at that visit?

3. When was the last time your teeth were cleaned?

4. When was the last time your teeth had x-rays taken?

5. a. Previous Dentist Name

Address

Phone

6. Have you made regular dental visits?

Yes No Don't Know

7. Have you lost any teeth or has any teeth been removed?

Yes No Don't Know

8. Have the lost teeth been replaced?

Yes No Don't Know

If yes, please select what it has been replaced with:

Fixed Bridge Removable Bridge Denture Implant

9. Have you ever had any problems/complications with previous dental treatments?

Yes No Don't Know

If yes, please explain.

10. Do you clench or grind your teeth?

Yes No Don't Know

11. Does your jaw click or pop?

Yes No Don't Know

12. Have you ever experienced any pain or soreness in the muscles of your face or around your ear?

Yes No Don't Know

13. Do you have frequent head, neck, or shoulder aches?

Yes No Don't Know

14. Do you have teeth sensitivity?

Yes No Don't Know

If yes, please circle one or more of the following that your teeth are sensitive to.

Hot Cold Sweets Pressure

15. Do your gums bleed or hurt?

Yes No Don't Know

16. How often do you brush your teeth?

17. Do you floss your teeth?

Yes No Don't Know

If yes, how often?

18. Are any of your teeth loose, tipped, chipped, or has shifted?

Yes No Don't Know

19. Have you ever had gum treatment or surgery?

Yes No Don't Know

What type of treatment or surgery?

Where?

When?

20. Have you had any orthodontic work done?

Yes No Don't Know

21. How do you feel about your teeth in general?

22. Do you have any questions or concerns?

Yes No Don't Know

By signing below, I certify that the above information is complete/accurate.

Patient/Guardian Signature

Date

Dentist's Signature

Date

Office Policy Notice

Dear Patients,

Appointments you schedule at our office is a time reserved just for you. Any changes in these appointments affect many patients.

We certainly understand circumstances arise that prevent patients from keeping appointments. If you find it impossible to keep an appointment, we require you to give us at least 48 hour notice prior to your appointed time. We will try to give you a courtesy call but you are ultimately responsible for your appointments.

If you miss, cancel or change your appointment with less than 48 hour notice, you will be charged a cancellation fee of $45.00. This policy is in place out of respect for your dental team and our clients. Cancellations with less than 48 hour notice are difficult to fill. By giving last minute notice or no notice at all, you prevent someone else from being able to schedule into that time slot.

Thank you in advance for your cooperation.

Sincerely,

Dr. Rongcal & Staff

Please sign below that you read and agree to these terms.

Guardian/Patient Signature

Date

Acknowledgement of Receipt of Statement of Privacy Practices

I acknowledge that I have received a copy of the Statement of Privacy Practices for the offices of D.B.A. Maul Island Cozy Dental. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility.

D.B.A. Maul Island Cozy Dental reserves the right to change the privacy practices currently described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed or otherwise transmitted to me.

ADDITIONAL DISCLOSURE AUTHORIZATION

In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my Protected Health Information to the person(s) identified below. (I understand that the default answer is "NO". Without indicating "YES" in answer to the each individual question, personal protected (PHI) cannot be shared with anyone unless otherwise allowed by HIPAA rules.)

Spouse Only

Yes No

Any Member of my immediate family: (Spouse, Children, Children's Spouses)

Yes No

Any Member of my extended family: (Parents, Grandchildren)

Yes No

Other

Name of Patient

Patient Signature (if 18 years old or older)

Patient's Personal Representative

Personal Representative's Signature

Representative's Telephone Number

Date

OFFICIAL USE ONLY BELOW THIS LINE

Provided Prior to Treatment?

Yes No

Date Statement Provided

Reason for not obtaining patient signature

Needed more time to review Statement of Privacy Practices

Wanted to consult another person before signing

Physically unable to sign

No reason offered

Other

If other, please specify.

Your information will be encrypted.