Dental Care Center

Patient Information

Thank you for choosing our practice for your dental needs. Please complete this form in ink. If you have any questions or concerns, do not hesitate to ask for assistance. We will be happy to help.

Date:

First Name:

Middle Initial:

Last Name:

Birthdate:

Address:

City:

State:

Zip:

Home Phone #:

Work Phone #:

Cell Phone #:

Email:

SSN:

Spouse’s or parent’s name:

Workplace:

Work Phone #:

Whom may we thank for referring you to us?

Insurance Information

(Please present your insurance card at time of check-in)

Click here If you have Additional Insurance

Authorization and Office Policy

I certify that I have read and understand the Dental Care Center information I was given today to the best of my knowledge. The 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 payers 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. I understand that payment will be due at time of service unless otherwise arranged prior to services rendered. I understand that if my account is not paid in full, interest charges may occur. I agree to be responsible for a “late cancellation” fee if I do not provide 24 hours notice when canceling/rescheduling an appointment for me or my dependents.

Name of person responsible for this account?

Relationship to patient:

Phone:

Address:

City:

State:

Zip:

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:

Date:

HIPAA Acknowledgement

I have reviewed your notice of privacy practices and understand that all my medical information will be used in accordance with the notice.

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 Name:

Signature:

Date

Relationship to Patient

Dental History

Former Dentist:

Date of last exam:

Date of last X rays:

Reason for today’s visit:

How often do you brush?

How often do you floss or use picks?

Do you wear any of the following dental appliances:

Dentures or Partials

Orthodontic retainers

Mouth guard

Sleep appliance

Whitening trays

Medical History

Have you ever had any serious illnesses or operations?

If yes, describe:

Physician:

Date of last visit:

Medications

Add Medications

Allergies

Add Allergies

(Women) Are you pregnant?

Yes No

Nursing?

Yes No

Taking birth control pills?

Yes No

Person to contact in case of emergency:

Phone #:

I have read my MEDICAL HISTORY and confirm that it adequately states past and present conditions.

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:

Date:

Your information will be encrypted.