Dayton Valley Dental Care Patient Forms

Here are some guidelines to help you understand our office philosophy. To better serve your needs, we strive for a clear, mutual understanding at all times

If Dr. Escobar feels a certain procedure is better served by another Dentist or Specialist, he will reefer you. Quality First!

Full mouth x-rays are necessary and required for the complete diagnosis both periodontal and restorative needs.

Dr. Escobar diagnoses what he feels you need, NOT what insurance pays for.

In order to build a positive relationship with the patient, we do require that parents, relatives, and friends remain in the waiting room unto; the appropriate time.

We appreciate the value of your time, and except for emergency situations, you can expect us to be on time for you. We will appreciate the same courtesy.

Payment is due at the time of service. We accept personal checks, cash, Care Credit, Visa, American Express, Discover, and MasterCard.

If you find it necessary to changer your appointment, we require 48 hours notice. Missed appointment charge is $50.00 for every hour we have reserved for you.

By signing this form, you agree to our office policy.

Parent/Guardian Signature

Date

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

Have you or another family member been seen at this office?

Yes No

Patient Information

Name

Date

Gender

Family Status

Social Security #

Birthdate

Home Phone

Work Phone

Ext

Best Time to Call

Physical Address

City

State

Zip Code

Mailing Address

***If Different from Physical Address***

City

State

Zip Code

Email Address

Emergency Contact

Name

Phone #

Spouse or Responsible Party Information

The following is for:

Patient's Spouse Person Responsible for Payment Self (See Above)

Name

Gender

Male Female

Family Status

Married Single Child Other

If Other, please explain

Social Security #

Birth Date

Home Phone

Work Phone

Ext

Best Time to Call

Address

City

State

Zip Code

Closest Relative Not Living With You

Name

Phone Number

Employment Information

The following is for:

The patient The person responsible for payment

Employer Name

Occupation

Phone Number

Street Address

City

State

Zip Code

Insurance Carrier

Self Spouse Other

Referral Information

Whom may we thank for referring you to our practice?

Another patient, friend

Another patient, relative

Office sign

Yellow Pages

Newspaper

School

Work

Name of person or office referring you to our practice:

Consent for Services

As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must determined before treatment.

All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed.

Any appointments that are failed, cancelled, or rescheduled with less than 48 hours notice will incur a $50.00 service charge per hour reserved to the patient account. This fee must be paid in full prior to scheduling a future appointment

Signature

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

Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. All patient portion will be due at time of service, this includes co-pays and deductible. Patients that carry Delta Dental will have fees due at the time of services rendered. This Office will help prepare the patient's insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.

Please be aware that all balances are due within 45 days, regardless if insurance has paid or not. A service charge of 1 ½% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days. After 90 days, all accounts will be turned over to a third-party collection. Any accounts requiring this action will incur all collection and legal cost.

I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination.

In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, or within five (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be as billed unless object to, by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if a suit be instituted hereunder.

I hereby authorize doctor or designated staff to take x-rays, study models, photograph and any other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of my dental needs.

Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agreed upon and to employ such assistance as required to provide proper care.

I agree to use anesthetics, sedatives and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.
I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form. I have read the above conditions of treatment and payment and agree to their content.

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, parent, or guardian

Date

Relationship to patient

Signature of guarantor of payment/responsible party

Date

Relationship to patient

Medical History

Patient Name

Have you been under the care of a medical doctor during the past two years?

Yes No

If yes, for what?

Physician's Name

Phone

Address

City

State

Zip Code

Have you taken any medication or drugs during the past two years?

Yes No

Are you taking any medication, drugs, or pills now?

Yes No

If yes, please list name and dosage

Add medication/dosage

Are you aware of having an allergic (or adverse reaction) to any medication or substance?

Yes No

If yes, please list

Have you been a patient in the hospital during the past 5 years?

Yes No

Do you require an antibiotic prior to dental treatment?

Yes No

Do you use more than two pillows to sleep?

Yes No

Do you have or have any disease, conditions, or problems not listed?

Yes No

If yes, please list

For Women, are you:

Pregnant?

Yes No

If yes, how many months?

Nursing?

Yes No

Taking birth control pills?

Yes No

I understand the above information is necessary to provide with 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 any 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.

Patient/Guardian Signature

Date

Doctor Signature

Date

Dental History

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

Patient Name

Medical Alert

What is the reason for your visit?

Date of Last Dental Visit

Last Dental Cleaning

Last Full Mouth X-Rays

What was done at your last dental visit?

Previous Dentist's Name

Phone Number

Address

City

State

Zip Code

How often do you have dental examinations?

How often to you brush your teeth?

How often do you floss?

What other dental aids do you use? (Water pik, electric toothbrush, toothpick, etc.)

Do you have any dental problems now?

Yes No

If yes, please describe

Are any of your teeth sensitive to:

Hot or Cold?

Sweets?

Biting or Chewing?

Have you noticed any mouth odors or bad tastes?

Yes No

Do you frequently get cold sores, blisters, or any other oral lesions?

Yes No

Do your gums bleed or hurt?

Yes No

Have your parents experienced gum disease or tooth loss?

Yes No

Have you notice any loose teeth or change in your bite?

Yes No

Do you?

Clench or grind your teeth while awake or asleep?

Mouth breathe while awake or asleep?

Have tired jaws, especially in the morning?

Smoke/chew tobacco?

Have you ever had:

Orthodontic treatment?

Oral surgery?

Periodontal treatment?

A bite plate or mouth guard?

A serious injury to the mouth or head?

If you've had a serious injury, please describe, including cause

Have you experienced:

Clicking or popping of the jaw?

Pain (joint, ear, side of face)?

Difficulty in opening or closing the mouth?

Headaches, neck aches, or shoulder aches?

Sore muscles (neck, shoulders)?

Are you satisfied with your teeth's appearance?

Do you like the color of your teeth?

Yes No

Are you happy with the size and spacing of your teeth?

Yes No

Are you interested in changing your smile?

Yes No

Would you like to keep all of your teeth all of your life?

Yes No

Do you feel nervous about having dental treatment?

Yes No

If so, what is your biggest concern?

Have you ever had an upsetting dental experience?

Yes No

If yes, please describe

Is there anything else about dental treatment that you would like us to know?

Yes No

If yes, please describe:

Notice of Privacy Practices

*You May Refuse to Sign This Acknowledgment*

I have received a copy of this office's Notice of Privacy Practices.

Signature

Date

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

You have my permission to discuss my dental appointments and treatment with the following people:

Add individual

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 acknowledgement

Other

If other, please specify

Your information will be encrypted.