New Patient Forms

General Information

Full Name

I like to be called:

Address

Apt. #

City

State

ZIP

Primary Phone #

Type of Phone

Home Mobile Work

Add additional contact #

Email Address

Social Security #

Date of Birth

Employment/Schooling Information

Patient's or Parent's Employer

Employer Phone

Business Address

Line 2

City

State

ZIP

Spouse/Parent's Name

Relationship to Patient

Spouse/Parent's Employer

Daytime Phone #

If Patient is a student, name of School/College

City

State

ZIP

Emergency Contacts

Emergency Contact Person

Relationship to Patient

Primary Phone #

Type of Phone

Home Mobile Work

Add additional emergency contact person

Referral Info

Whom may we thank for referring you?

Current Needs

What is your goal for today?

Date of last dental visit:

Do you have concerns about today's visit?

Are you seeking a second opinion?

Yes No

Regarding what treatment?

Responsible Party

If the Responsible Party is NOT the patient, please fill out the following information.

Name of Person Responsible for Account

Relationship to Patient

Date of Birth

Employer

Address

Line 2

City

State

ZIP

Primary Phone #

Type of Phone

Home Mobile Work

Payment Information

The options for payment will be explained to you after treatment plans have been discussed. Payments may be made in cash, check, VISA, MasterCard, American Express, Discover, or we can arrange third party financing for you.

Do you have Dental Insurance?

Yes No

If you have dental insurance, please provide us with the appropriate information so we can submit claims electronically for prompt reimbursement. As a courtesy to you, we will fill out the necessary forms for your insurance so you are reimbursed directly. We will make every effort to help you maximize your benefits.

Appointments are scheduled to allow sufficient time to attend exclusively to your needs. For appointments which are not kept or cancellations with less than 48 hours notice, we reserve the right to charge cancellation fee.

Photography Authorization & Release

I hereby give Dr. Joel Singer authorization to use my photographs/slides for educational or promotional purposes.

Medical History

Physician's Name

Date of last physical exam:

Has there been any change in your general health in the past year?

Are you currently under the care of a physician?

Yes No

If "Yes", for what reason?

Are you currently taking any prescription medications?

Yes No

If "Yes", please list medications:

Add prescription medication

Do you smoke or use tobacco products?

Yes No

If "Yes", how much per-day use?

WOMEN: Are you...

Pregnant

Nursing

On Birth Control

If Pregnant, how many months?

Have you been hospitalized in the last 5 years?

Yes No

If "Yes", when?

What for?

Have you ever been premedicated before dental treatment?

Yes No Not sure

Dental Health & Appearance

Are you having discomfort at this time?

Yes No

Have you been to a dentist in the last 6 months?

Yes No

Have you lost any teeth other than wisdom teeth?

Yes No

Have you ever had missing teeth replaced?

Yes No N/A

Have you had any complications with a tooth removal?

Yes No N/A

If you have had teeth replaced, are you happy with the results?

Yes No N/A

Are your teeth sensitive to heat, cold, sweet, sour, or when chewing?

Yes No

Have you ever had your teeth straightened or had orthodontics (braces) in the past?

Yes No

Do your gums bleed?

Yes No

Have you ever had treatment for gum problems?

Yes No

Do you ever feel (or have been told) that you don’t have fresh breath?

Yes No

Do you clench your teeth during the day or suspect you do during sleep?

Yes No

Do you have any pain in, or around, your ears?

Yes No

Are you aware of any swelling or lumps in your mouth?

Yes No

Do you ever experience a burning sensation in your mouth?

Yes No

Have you ever had professional instructions on home dental care?

Yes No

How do you feel about dental visits?

Relaxed Anxious Neutral

Are you familiar with sedation and relaxation methods that can be combined with dental treatment?

Yes No

Are your teeth as white as you would like?

Yes No

Have you ever considered (or discussed) improving the appearance of your smile?

Yes No

How often do you brush your teeth?

How often do you floss your teeth?

Please list the obstacles that have prevented you from achieving your oral health and appearance goals in the past:

Notice of Privacy Acknowledgment

I understand that, under the Health Insurance Portability & Accountability of 1996 (“ HIPPA”), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly
Obtain payment from third-party payers.
Conduct normal healthcare operations such as quality assessments and physician certifications.

I have received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy practice from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Private Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations, I also understand that you are not required to agree to my requested restrictions but if you do agree then you are bound to abide by such restrictions.

Patient Authorization

I understand the above information is necessary to provide me 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 healthcare provider or agency, who may release such information to you. I will notify Dr. Singer of any change in my health or medication.

Patient Full Name

Today's Date

Parent or Guardian Name

Relationship to Patient

I request that my signature be represented by the above electronic signature and consent to recipients of electronic documents that I sign receiving personal information about me, including my email and IP addresses.

Your information will be encrypted.

New Patient Forms

General Information

Employment/Schooling Information

Emergency Contacts

Referral Info

Current Needs

Responsible Party

Payment Information

Photography Authorization & Release

Medical History

Dental Health & Appearance

Notice of Privacy Acknowledgment

Patient Authorization

Joel D. Singer, DMD