New Patient Form

Please correct the errors described below.

Patient Information (Confidential)

  • Please read all notices in the waiting room. Copies of any of these documents will be provided (when requested) including: cancellation policy and associated fees, our HIPPA Notice of Privacy Practices and Authorization for Release of identifying health information
  • Offices are Audio & Video monitored & recorded 24 hours a day.
  • We will be using a digital signature for all future transactions. You agree that this is the same as a written signature.
  • My medical information will be entered into the computer system directlly (Fast Check-in) and will be updated by me each time I come in for a recall, or upon a change in my medical history or medication, or upon request of this office.
  • Our office is OSHA, HIPPA, and Red Flag Rule compliant. Copy of all forms are available upon request.
  • I authorize the dentist, hygeinist, and assistants to examine, take radiographs, to do any and all necessary treatment on me.
  • I allow my photos or X-rays to be shown to other patients for teaching purposes.

For your convenience, we offer the following methods of payment:

  • Debit Card
  • MasterCard
  • Visa
  • American Express
  • Check

Payment is expected at a time of service.

  • Cancellation Policy: I understand that I will pay a fee for either BROKEN APPOINTMENTS or APPOINTMENTS CANCELLED/CHANGED/RESCHEDULED with less than two (2) Business Days notice. Leaving messages does not constitute contact/communication. (Ask receptionist for current fee or see posted sign.) Certain longer appointments, such as crowns, onlays, root canals, implants, extractions, scaling & root planing, etc... may require a non-refundable deposit upon making the appointment (usually it's approximately 25% of the estimated out of pocket cost). This contract between City Dental DC and me shall not become effective until it is signed and any initial deposit amount due has been paid. At the time the contract takes effect City Dental DC shall reserve the date and time agreed upon. For this reason, in the event that I cancel the contract for any reason, all monies paid shall be forfeited by me and retained by City Dental DC in order to offset its loss of business. My failure to pay the fees may result in dismissal from the practice, inactivation of my chart, delinquent and collection charges.
  • Delinquency Policy: I understand if my account is delinquent, I will be charged an additional 33% to cover colleciton expenses and a 1.8% monthly finance charge from time the services are rendered. I also understand that not all procedures are covered by my insurance. I am responsible for any amount not covered by my insurance, including the payment of procedures scheduled but cancelled after the doctor has commenced work and/or the doctor has set asid the time for the procedure and I cancel.
  • City Dental DC verifies my insurance benefits as a courtesy and it is my responsibility to know my plan benefits.
  • If your insurance has changed please notify us two (2) business days in advance so we can get an updated breakdown. If we are unable to verify your insurance, then you will need to pay out of pocket and process your own insurance using the receipt from that day's visit. If you choose to reschedule until it is verified, then the cancellation policy takes effect.

Patient Dental History

I certify that I have read and understand all of the above and that I have answered all of the questions accurately. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and records of any treatment or examination rendered to me, or my child, during the period of such dental care to third party payors 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 including cancellation fees as stated above.

Oral Screening Consent Form

Complete each time the examination is performed and place in the patient's file.

Our practice continually looks for advances to ensure that we are providing the optimum level of oral health care to our patients. We are concerned about oral cancer and look for it in every patient. One American dies every hour from oral cancer. Late detection of oral cancer is the primary cause that both the incidence and mortality rated of oral cancer continue to increase. As with most cancers, age is the primary risk factor for oral cancer. Tobacco and alcohol use are other major predisposing risk factors but more than 25% of oral cancer victims have no such life style risk factors. Studies also suggest that human papillomavirus (HPV) plays a role in more than 20% of oral cancer causes. *Oral Cancer risk by patient profile as follows:

  • Increased risk: Patients ages 18-39, Sexually active patients (HPV)
  • High risk: Patients age 40 and older; tobacco users (ages 18-39), any type within 10 years)
  • Higher risk: Patients age 40 and older with lifestyle risk factors (tobacco and/or alcohol use); previous history of oral cancer)

We have recently incorporated VELscope powered by Sapphire into our oral screening standard of care. We find that using VELscope powered by Sapphire along with standard oral cancer examination improves the ability to identify suspicious areas at their earliest stages. Velscope powered by Sapphire, along with the doctor's visual exam, is similar to proven early detection procedures for other cancers such as mammography, Pap smear, and PSA. VELscope powered by Sapphire is a simple and painless examination that gives the best chance to find any abnormalities at the earliest poossible stage. Early detection of pre-cancerous tissue can minimize or eliminate the potentially disfiguring effects or oral cancer and possibly save your life. The VELscope powered by Sapphire exam will be offered to you annually.

What to expect at your First visit at City Dental DC

Hello, and welcome to City Dental DC, where we hope to make your dental experience better!

This document will explain all of the steps that you need to ensure a smooth first dental experience at City Dental DC. There are quiet a few, so please help us, so we can help you.

ALL of the information below must be given in order to set up your first appointment. If you do not have all the required information we will ask you to all us back with that needed information. Then we can schedule an appointment. If you feel more comfortable you can stop by one of our locations to hand deliver this information and make an appointment there.

1. Please call the location that you wish to be seen at and have prepared the following information: (this call may take up to 10 minutes to complete)

  • Are you requesting a: 1) New Patient Full Exam and Cleaning (1hour and 30 min); 2) Emergency visit: to look at one particular area of pain (30 min); 3) Consultation only (Invisalign, sleep apnea, periodontal, oral surgery, etc...) (30 min)
  • Any problems/pain?
  • How long since your LAST regular dental cleaning/appointment?
  • If it was within a year, did they take X-rays and can those be sent to us PRIOR to your appointment date? (if not, your insurance may not cover the x-rays and you will need to pay out of pocket in order to have a comprehensive exam).
  • Who is referring you or how did you hear about us?
  • Two (2) good phone numbers and your primary email in order to facilitate good communication.
  • Your date of birth and home address
  • Is this insurance yours, parent's, spouse's, partner's? If not, we need their SS#.
  • Your insurance company's name and phone number?
  • Who is your employer?
  • Do you have a secondary plan?
  • Your Group Number and Subscriber ID Number and possibly your SS# will be needed in order to set an appointment date. If you are paying out of pocket, this information may not be relevant.
  • Is there a City Dental DC dentist or hygienist that you prefer?
  • What day of the week and what time: morning, mid-day or afternoon is best for you?

2. If you have insurance, we will call them for a breakdown and will notify you PRIOR to your appointment if there is a problem or issue. This way we can resolve it PRIOR to your first visit.

3. Please have your New Patient Information and Oral Cancer Screening Forms completed PRIOR to your arrival. Please arrive 15 minutes early if you need to fill out those forms in the office.

4. When you arrive you will be greeted by one of our Front Desk associates. They will ask to make a copy of your Government issued ID and your insurance company ID card. (some companies may not give them out, but those that do, we are required to see). You will be asked to sit at a Kiosk and fill out your medical history and other basic info.

5. You will be escorted back, by one of our staff, to one of our dental rooms, where they will go over a series of questions, take a few low dose radiation digital X-rays, then walk you to another room for another X-ray (Panoramic - the one that goes around your head while you stand). You will return to the room and either the City Dental DC hygienist or dentist will come in to begin your evaluation.

6. The City Dental DC dentist will do your exam, take photos, show and explain to you any needed treatment and will go over an approximate cost for the treatment. You will then have the opportunity to discuss any questions you have with them. Once you have come to some conclusion as to the next step, you will go to the Front Desk associate, sign a Treatment Plan stating that you understand what customized treatment your City Dental DC dentist has suggested for you. You are under NO obligation to follow thru with any further treatment and if requested, at no charge to you, we will send that information to another dentist of your choice for a second opinion.

We have a few office Policies that need to be discussed ahead of time:

  • There is Free parking in our outlined spaces in the alley behind our 1221 Mass Ave office. There is an entrance for your convenience directly into the office from those spaces.
  • If your insurance has changed please notify us 48 hours in advance so we can get an udated breakdown. If we are unable to verify your insurance then you will need to pay out of pocket and process your own insurance, using the receipt from that day's visit. If you choose to reschedule until it is verified then the Cancellation policy takes effect.
  • City Dental DC verifies your basic insurance benefits as a courtesy and it is your responsibility to know your plan benefits.
  • Cancellation policy: You must contact one of our front desk associates two (2) full business days in advance to cancel or reschedule your appointment. If not, there is a $60 broken appointment fee. Leaving messages does not constitue contact. See office for details.

Thank you for trusting us with your dental and cosmetic needs!

Your message will be encrypted and can only be read by City Dental DC.