New Patient Form

Patient Information

Full Name

List your First Name, Middle Initial, and Last Name

Social Security #

Address

City

State

Zip Code

Home Phone

Cell Phone

Email Address

Age

Birth Date

Sex

Male Female Other

Marital Status

Single Married Divorced Widowed

Employer

Occupation

In case of emergency, who should be notified?

Phone Number

Whom may we thank for referring you?

Family Information

Please list the names and birthdates of your immediate family members.

Full Name

Birth Date

Full Name

Birth Date

Full Name

Birth Date

Full Name

Birth Date

Insurance Information

Do you have dental insurance?

Yes No

Person Responsible for your Dental Insurance

Relationship to Patient

Birth Date

Social Security #

Address (if different from patient's)

City

State

Zip Code

Person Responsible Employed by

Occupation

Insurance Company

Phone Number

Group Number

Subscriber ID

Names of other dependents covered under this plan

Is patient covered by additional dental insurance?

Yes No

What is the subscriber's name?

Social Security #

Insurance Company

Phone Number

Group Number

Subscriber Number

Dental History

Reason for visit

Date of last dental care

Leave blank if you are unsure

Previous Dentist

Date of last dental x-rays

Leave blank if you are unsure

How often do you brush?

How often do you floss?

Any additional questions or concerns?

Medical History

Physician's name

Date of last visit

Leave blank if you are unsure

Have you had any serious illnesses or operations?

Yes No

Please describe any serious illnesses or operations

Have you been diagnosed with Osteoporosis?

Yes No

Have you been treated with a bisphosphonate (Fosamax, Actonel, Reclast, etc)?

Yes No

Are you pregnant? (Women)

Yes No

Nursing?

Yes No

Taking birth control pills?

Yes No

If the patient is a child, what is his/her weight?

Medications

List any medications you are currently taking (include over-the-counter pain reliever or allergy medication)

Allergies

Aspirin

Codeine

Ibuprofen/Advil

Local Anesthetic

Latex

Penicillin

Sulfa

Other

None

What other allergies do you have?

Pharmacy Name

Pharmacy Phone Number

The above information is accurate and complete to the best of my knowledge. I will not hold my dentist or any member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form.

Enter your Full Name to acknowledge

Today's Date

Assignment and Release

Name of Insurance Company(ies)

I, the undersigned, have insurance with the company(ies) listed above and assign directly to Dr. Stephanie Scheich or Dr. Jeff Scheich all benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of confirmation on all of my insurance submissions whether manual or electronic. I have also read and understand this office's HIPAA policies and guidelines.

Enter your Full Name to acknowledge

Today's Date

Minor/Child Consent

Are you filling this out on behalf of a minor/child?

Yes No

Name of minor/child

I, being the parent or guardian of minor/child (named above) do hereby request and authorize the dental staff to perform necessary dental services for my child, including but not limited to x-rays, and administration of anesthetics which are deemed advisable by the doctor, whether or not I am present at the actual appointment when the treatment is rendered.

Enter your Full Name to acknowledge

Today's Date

Financial Agreement

I acknowledge that payment is due at the time of treatment, unless other arrangements are made. I agree that parents/guardians are responsible for all fees and services rendered for treatment of a minor/child. I accept full financial responsibility for all charges not covered by insurance.

Enter your Full Name to acknowledge

Today's Date

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