Dental History

OAK VALLEY DENTAL ASSOCIATES

Please correct the errors described below.

Welcome! So that we may provide you with the best possible care, please complete both sides of this medical/dental history form. All information is completely confidential.

Are any of your teeth sensitive to:

Do you:

Home Care

Any Family History of:

Have you ever had:

Have you experienced:

Would you like:

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.

MEDICAL HISTORY

If yes, please specify the substance(s) and your reaction(s):

Add another substance:

I understand the above information is necessary to provide me dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of change in my health or medication. 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.

ADULT REGISTRATION FORM

Add another family member

ACCOUNT INFORMATION

DENTAL INSURANCE INFORMATION

Primary Dental Insurance

Secondary Dental Insurance

AUTHORIZATION AND RELEASE

Your payment/insurance co-payment is due at the time service is rendered. We accept cash, check and credit cards. I authorize Oak Valley Dental Associates to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during period of such dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to Oak Valley Dental Associates 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. 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.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

*You may refuse to sign this acknowledgement*

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.

For office use only

Your information will be encrypted.