Miami Dental Intake Form

Patient Information

First name

Last name

Date of birth

Occupation

Gender

Who may we thank for referring you to our office?

Contact Information

Phone number

Cell Phone

Work Phone

Email address

Home Address

City

State

Zip Code

Place of Employment

Spouse Name

Spouse Phone Number

Emergency Contact

Add another emergency contact

Physician Contact

Add another physician contact

Insurance Information

Name of insurance policy holder

Name of primary insurance holder if different

Member ID

Policy Number

Group Number

Medical History

Have you ever been told that you need to take antibiotics prior to dental treatment? If yes, why?

Any other conditions not mentioned above?

For Women Only

Are you currently pregnant or may be pregnant?

Are you currently nursing?

Are you on birth control?

Do you have any of the following allergies?

Penicillin

Aspirin

Codeine

Latex

Local anesthetic

Percocet

Sulfa

Other Allergies

Are you currently taking any medications? PCN or other antibiotics? Please list.

Is there anything else regarding your medical history that we should be aware of?

Reasons for Visit

Date of last dental visit

Date of last dental cleaning

Date of last dental x-rays

Is there anything else regarding your dental treatment that we should be aware of?

Payment options

Payment is expected at the time of service. Cash, check, Mastercard, Visa, American Express, Discover, and Care Credit are accepted as methods of payment.

If you have dental insurance, we want you to receive the full benefit of it. Our office staff can assist you in completing your insurance forms and verifying the coverage that your particular program provides. We will submit all necessary documentation for you to receive reimbursement (if applicable) from your insurance company.

General Consent For Treatment

This is to verify that I; the undersigned; hereby give Drs. Ressler / Hirschl / Lelchuk and their hygienists/assistants to perform whatever examination, acquisition of x-rays, or treatment deemed necessary and to the use of an anesthetic (or analgesic) as indicated and that the medical history I have provided is correct.

On rare occasions, some unusual, unexpected and severe reactions or complications can occur, but we feel it would be impractical and misleading to describe in detail all those that could arise during or following treatment. Your doctor is aware of these risks and feels that the indications for treatment and benefits vastly outweigh the possible risks of the procedure. If you have further questions, please feel free to ask us before the procedure has begun.

To avoid misunderstanding regarding insurance, we wish our patients to know that all professional services rendered are charged directly to the patient and that the patients are personally responsible for payment of fees. We will prepare necessary forms or reports to help you obtain your benefits from insurance companies, upon receipt of full (or partial) payment of fees. We do not render our services on the basis that insurance companies will pay all our fees. Each fee is individual for the individual patient.

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

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