Update Form

Welcome to our office. We will do our best to make your appointments as convenient and as pleasant as possible. We askthat you please complete ALL paperwork so that we may better serve you. If at anytime you have any questions, please feel free to ask any of our team members for help.

Patient Information (Confidential)

Today's Date:

Patient Name:

Date Of Birth:

Has ANY of the following information changed since your last dental visit? Please indicate yes or no. If YES, then please update changed information on the pages we will provide.

Home Address:

Yes

Contact Information (E-mail, Cel Phone, Emergency Contact):

Yes

Marital status:

Yes

Insurance Information:

Yes

Medical History ( illness, surgery, allergies):

Yes

Changes in Medications:

Yes

I, the patient or guardian, certify that the above information is complete and accurate and I authorize any information to be released regarding medical or dental history, treatment, or credit reference to LifeSmiles of New Hope, P.C.. I understand that if there is ANY change in the information provided above, it is my responsibility to notify the office in writing. If I do not inform LifeSmiles of New Hope of these changes I will be responsible for ALL charges related to my visit.

Patient, Parent or Guardian name

Signature

Date

Time

Today's Date

INFORMED CONSENT

Appointment Times

ALL appointments are reserved for you at times that are mutually agreeable to you and the practice. If you are unable to keep a scheduled appointment, notify us immediately. We require a 24 hour notice so that the appointment may be offered to another patient. I understand that I will be charged a $100 fee for appointments cancelled without 24 hours notice. If I miss three appointments without notice, I will be dismissed from the practice.

Please initial that you have read, understand, and consent to this paragraph:

Dental / Medical Records

I hereby authorize LifeSmiles to take necessary records such as study models, digital scans, photographs, radiographs, CBCT, or any other diagnostic aids deemed appropriate by LifeSmiles, its doctors and team members to make a thorough diagnosis of my condition(s). WE CANNOT OFFER YOU ANY DIAGNOSIS WITHOUT CLINICAL RECORDS. In addition to private practice, Dr. Parbhoo is an educator of doctors/ healthcare professionals worldwide. I understand and consent to the use of my clinical records, with a fictitious name, for the purpose of advertising and educating and forever release LifeSmiles and Dr. Parbhoo from any claim, demands or liability.

Please initial that you have read, understand, and consent to this paragraph:

Insurance Benefits

I, the patient or guardian, authorize the release of any information, including diagnosis and records of any treatments or examinations rendered, to my insurance company or consulting professionals. The release to the insurance company is solely for the purpose of facilitating the billing and reimbursement directly to the dentist of insurance benefits under which I am entitled. I understand that I am given treatment plans with ESTIMATES of what the insurance plan may pay. I know that I am 100% responsible for all fees not paid for by my insurance plan.

Please initial that you have read, understand, and consent to this paragraph:

Documents

Unless you are paying in cash, you will be required to provide a government issued photo ID.

If you are filing an insurance claim, you will additionally be required to provide a current and valid insurance card as well as a credit card for any unpaid balances past 90 days.

Please initial that you have read, understand, and consent to this paragraph:

Patient, Parent or Guardian name

Signature

Date

Time

Today's Date

INFORMED CONSENT

Financial Policy

You will be given a copy of ALL fees associated with your treatment prior to any services being rendered. We do this because you are solely responsible for 100% of fees charged.
Depending on the type of treatment, payment is expected either prior to, or at the time services are rendered.
All patients are required to keep a credit card on file, and balances past 90 days will automatically be charged to that card. Please speak with the financial coordinator if you need to make other arrangements.
For your convenience, we accept cash, check, major credit cards, and offer opportunities for extended financing through MoreMastercard and CareCredit.
Patients with PPO Dental plans. You are receiving a highly discounted fee for your treatment, therefore you are NOT entitled to ANY additional discounts offered by the practice. ANY balance remaining on your account past ninety days will be automatically charged to your card.

Please initial that you have read, understand, and consent to this paragraph:

Administrative Appointment (Non-emergency visits)

You will be scheduled for an administrative appointment for the following reasons:

We will review together consent forms regarding what treatment is to be rendered, risks, benefits and any but not all potential complications associated with the treatment. You will be asked to sign these consent forms ONLY after you have read them, asked questions and fully understand, and are ready to give your full INFORMED CONSENT.
We will review together your medical history, potential risks associated any conditions you may have and give you any necessary prescriptions.
We will review together ALL fees associated with your treatment. You will be expected to take care of any financial arrangements/ payments at this appointment in order to reserve an appointment for your treatment.

Please initial that you have read, understand, and consent to this paragraph:

Patient, Parent or Guardian name

Signature

Date

Time

The dental care you receive has an important interrelationship with the health problems that you may have, and medications you may be taking. It is required that you provide the following information to help us treat you as effectively and safely as possible. If you have questions, require additional forms or need help, please do not hesitate to ask a LifeSmiles team member.

Please initial that you have read, understand, and consent to this paragraph:

Medical History and Present Illness (Confidential}

Today's Date

Patient Name

DOB

Height

Weight

Allergies-Hypersensitivities

List ALL drugs (Rx or OTC) currently being taken

Name of Medication

Dosage

How Taken

I understand that if there is ANY change in the information provided above, it is my responsibility to notify the office in writing. I certify that the above information is complete and accurate.

Patient, Parent or Guardian name

Signature

Date

Time

Please initial that you have read and understand this paragraph:

Medical History and Present Illness (Confidential}

Today's Date

Patient Name

Date Of Birth

Are you under a physician's care now?

Yes

If yes, name and phone of treating physician(s)

Have you ever been hospitalized or had a major operation in the past 5 years?

Yes

If yes, explain:

Have you ever had a serious head or neck injury?

Yes

If yes, explain:

Are you taking or have you taken Bisphosphonate for osteoporosis: such as Actonel, Boniva, Fosamax, Zometa or Aredia?

Yes

If yes, explain:

Do you smoke, use chewing tobacco, consume alcohol or other controlled substances?

Yes

If yes, explain:

Do you take ANY non-prescription medications, herbal supplements, aspirin, ibuprofen, multivitamins, Vitamin E?

Yes

If yes, explain:

Have you ever been advised to take Pre-medication for dental visits?

Yes

If yes, explain:

Women: Are you pregnant, trying to get pregnant, taking birth control or nursing?

Yes

If yes, explain:

I understand that if there is ANY change in the information provided above, it is my responsibility to notify the office in writing. I certify that the above information is complete and accurate.

Patient, Parent or Guardian name

Signature

Date

Time

Medical History and Present Illness (Confidential)

Today's Date:

Patient Name

Date Of Birth

DO YOU HAVE, OR HAVE YOU EVER HAD ANY OF THE FOLLOWING?

AIDS/HIV

Yes No

Allergies

Yes No

Alzheimer's Disease

Yes No

Anaphylaxis

Yes No

Anemia

Yes No

Angina / Chest pains

Yes No

Arthritis / Gout

Yes No

Artificial Heart Valve

Yes No

Artificial Joint

Yes No

Asthma

Yes No

Blood Disease

Yes No

Blood Transfusion

Yes No

Bruise Easily

Yes No

Cancer

Yes No

Chemotherapy

Yes No

Celiac Disease

Yes No

Congenital Heart Disorder

Yes No

Convulsions

Yes No

Cortisone Medicine

Yes No

Diabetes

Yes No

Drug Addiction

Yes No

Eating Disorder

Yes No

Emphysema

Yes No

Epilepsy or seizures

Yes No

Excessive Bleeding

Yes No

Excessive Thirst

Yes No

Fainting spells/ dizziness

Yes No

Frequent or persistent Cough

Yes No

Frequent Diarrhea

Yes No

Frequent Headaches

Yes No

Glaucoma

Yes No

Heart attack/ Failure

Yes No

Heart Murmur

Yes No

Heart Pace Maker

Yes No

Heart Trouble/ Disease

Yes No

Hemophilia

Yes No

I understand that if there is ANY change in the information provided above, it is my responsibility to notify the office in writing. I certify that the above information is complete and accurate.

Patient, Parent or Guardian name

Signature

Date

Time

Medical History and Present Illness (Confidential}

Today's Date:

Patient Name

Date Of Birth

DO YOU HAVE, OR HAVE YOU EVER HAD ANY OF THE FOLLOWING?

Hepatitis A,B,C,D,OR E

Yes No

Implants-Hip/Breast/ Knee/Tooth

Yes No

HPV

Yes No

High Blood Pressure

Yes No

Hives or Rash

Yes No

Hypoglycemia

Yes No

Irregular Heartbeat

Yes No

Kidney Problems

Yes No

Leukemia

Yes No

Liver Disease

Yes No

Low Blood Pressure

Yes No

Lung Disease

Yes No

Mitra! Valve Prolapse

Yes No

Osteoporosis

Yes No

Periodontal disease

Yes No

Psychiatric Care

Yes No

Radiation Treatments

Yes No

Recent Weight Loss

Yes No

Renal Dialysis

Yes No

Rheumatic Fever

Yes No

Rheumatism

Yes No

Scarlett Fever

Yes No

Stomach/Intestinal disease/ Ulcers

Yes No

Shortness of Breath

Yes No

Sickle Cell Disease

Yes No

Sinus Trouble

Yes No

Special Diet

Yes No

Spina Bifida

Yes No

Shingles/Herpes/Cold Sores

Yes No

Stroke

Yes No

Swelling of Limbs

Yes No

Thyroid Condition

Yes No

Tonsillitis

Yes No

Tuberculosis

Yes No

Tumors or Growths

Yes No

Yellow Jaundice

Yes No

I understand that if there is ANY change in the information provided above, it is my responsibility to notify the office in writing. 1 certify that the above information is complete and accurate.

Patient, Parent or Guardian name

Signature

Date

Time

Your information will be encrypted.