New Patient Intake Form

**IF YOU ARE UNABLE TO FILL OUT THESE FORMS ONLINE. Please do not hesitate to call our office and we will be happy to email you these forms or please drop by our office and say ' Hi ' and we will give you the forms to fill out in pen.

BARBARA DELUCIA DENTISTRY NEW PATIENT INTAKE FORM

A Master of The Academy of General Dentistry

DENTISTRY FOR PEOPLE AGES 65 and ABOVE

THANK YOU for contacting us for an appointment.

Our office is ‘ Dedicated to Preserving Your Teeth ‘ through health and restorative services.

We are a small, one dentist, private practice. >>( )> . Dr DeLucia is a cosmetic restorative dentist... and yes Dr DeLucia performs all the dental cleanings.

***We only treat people ages 65 and above *** as Dr DeLucia has a special interest in the diseases and disorders of people within this age group.

We only intake a certain number of each insurance to avoid the office being inundated with any single insurance. We give equal opportunities to all the insurances.. Any changes in insurance will require the patient to be inactivated and reactivated into the office on the month that we begin to take that insurance again. All insurance changes must be presented prior to making your next appointment to determine eligibility to re-enter the practice under that plan.

Oh....and one more thing....if you have another dentist in another state or country please be aware that for our patients to remain a patient, ALL x-rays and ALL restorative treatment must be performed by Dr DeLucia once you are a patient of record.. Cleanings can be performed by a dentist in another location to help our patients that are 'snow birds' or ''southern country birds'. This is important for treatment consistency and predictable results. Thank you for understanding our responsibility to you as our patient.

We need some information prior scheduling you into our office.

Last Name

First Name

Patient Birthdate ( xx/xx/xxxx )

Patient Cell Phone Number...................(xxx-xxx-xxxx).

I do not have a cell phone. My home phone is: ( xxx-xxx-xxxx )

Patient Email address

Patient Residence Address ( house number and street )

City, State, Zip Code

Neighborhood you live in. (OTOW, Marion Landing etc.)

I have no dental insurance ( If this box is checked, please pass by all the insurance questions )

I have dental Insurance. ALL INSURANCE INFO MUST BE GIVEN TO THE DENTAL OFFICE PRIOR TO THE FIRST APPOINTMENT. ( If this box is checked please fill in ALL the information concerning your insurance below )

To fill out the information below, please check your insurance card or your insurance website or call your insurance company.

I have contacted my insurance company and have been informed that Barbara DeLucia DMD / DeLucia Dentistry is in the network of providers for my policy. I understand that DeLucia Dentistry does not obtain this information and takes no responsibility for this information. ( If this box is unchecked, your intake will be delayed. )

The Name of your Insurance Company

City, State, Zip Code

Insurance Plan Name

Insurance Phone Number ( for Dental Division ) (xxx-xxx-xxxx)

Insurance Group Name

Employer Name ( if a Group Coverage )

Subscriber / Insured's Name ( the persons name who obtained the insurance )

Subscriber's Date of Birth

Subscriber ID Number

Payor ID Number

The date your insurance becomes (or became) active for coverage benefits with month/day/4 digit year (xx/xx/xxxx)

Social Security Number.................(xxx-xx-xxxx)

Check two of the boxes below that apply to your particular insurance:

PPO

HMO

Individual Coverage

Group Coverage

I have a secondary dental insurance and I will write the above needed information into the below box of "Other Information I Need To Convey" .

For us to obtain your insurance information, we need a copy of the front and the back of your insurance card emailed to staff@DeLuciaDentistry.com.

I have emailed or taken to the office a copy of the front and back of my insurance card.

Pease check all areas that apply to your existing situation. At least one box must be checked to schedule your appointment:

I have an area of pain, sensitivity, broken tooth, broken crown or other need that needs immediate attention. Please describe the exact problem below:

I am having a problem with a dental appliance ( i.e. crown, bridge, partial, bite splint, night guard, implant ). Please state the type of appliance and the problem below:

My prior dentist told me I had some dental problems that need treatment as soon as possible. Please describe in detail below:

I am in need of dental implants / or desire cosmetic changes. Please describe below:

I am a patient with chronic periodontal problems and I need both a dentist and a periodontist.

I have a denture / set of dentures (we dont repair or fabricate dentures with no existing teeth).

I am a prior patient of Dr DeLucia's.

I have no dental problems of which I am aware.

Please notate below any disability you may have including dementia.

Please describe here:

Other information I need to convey:

In dentistry, we find that due to emergencies and unforeseen events with certain cases, it is impossible to avoid running behind. Our office does not cut corners or speed up procedures to stay on time. Please notate, which of the following statements best simulates your perspective.

I understand; as I would want the office to take the extra time for me with my treatment.

I have an expectation that if I book my appointment at a particular time, my appointment should start at that stated time.

Please write the name of the person we should thank for your referral.

**THANK YOU FOR YOUR GOOD HYGIENE DURING YOUR APPOINTMENT** . We have upholstered chairs and desire to keep them clean for all patients. Our dental chair has a 300 pound weight limit. If your weight exceeds this, please call the office for special assistance.

Please be informed that we reserve the right to dismiss patients with an adversarial attitudes and displays of anger; as a dentist-patient relationship should be one of trust and respect.

WE PROMISE TO TREAT YOU WITH KINDNESS AND RESPECT !

Thank you for your information.

Name of person filling out this form

Date

Your information will be encrypted.

New Patient Intake Form

**IF YOU ARE UNABLE TO FILL OUT THESE FORMS ONLINE. Please do not hesitate to call our office and we will be happy to email you these forms or please drop by our office and say ' Hi ' and we will give you the forms to fill out in pen.

BARBARA DELUCIA DENTISTRY NEW PATIENT INTAKE FORM

DENTISTRY FOR PEOPLE AGES 65 and ABOVE

**IF YOU ARE UNABLE TO FILL OUT THESE FORMS ONLINE. Please do not hesitate to call our office and we will be happy to email you these forms or please drop by our office and say ' Hi ' and we will give you the forms to fill out in pen.

Dr Barbara DeLucia