New Patient Forms

How did you hear about Woolf Dental?

Please select all that apply

Website

Internet

Insurance

Work

Advertisement/Flyer

Patient/Friend

Other

Name of Person/Office referring you to our practice

Patient Information

First name

Last name

Address

City

State

ZIP

Cell Phone

Home Phone

Email address

Preferred Form of Contact

Cell

Home

Gender

Date of birth

Emergency Contact

Add another emergency contact

Medical History

Date of last dental visit

Reason for Visit

Due Date

If pregnant, what is the estimated due date?

Other Conditions

Please list any conditions you have not listed above.

Do you have any of the following allergies?

Penicillin

Aspirin

Codeine

Latex

Local anesthetic

Percocet

Sulpha

Valium

Other Allergies

List all Medications you are currently taking:

Add another medication

Preferred Pharmacy Name

Major Crossroads

Do you smoke?

Yes No

Have you ever had any complications following dental treatment?

Yes No

If Yes, please explain:

Have you been admitted to a hospital or needed emergency care during the past two years?

Yes No

If Yes, please explain:

Are you now under the care of a physician?

Yes No

If Yes, please explain:

Name of Physician

Phone

Do you have any health problems that need further clarification?

Yes No

If Yes, please explain:

To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail.

Spouse or Responsible Party Information

The following is for the person responsible for payment if different than patient. i.e. parent, spouse, guardian, fiduciary.

Name

Marital Status

Married Single Child Other

Other

Relationship to Patient

Parent Spouse Guardian Fiduciary Other

Other

Add another number

If different than patient information:

Address

City

State

ZIP

Insurance Information

Primary

Name of insurance policy holder

Is insured also a patient?

Yes No

Insured's Date of Birth

ID #

Group #

Insurance ID Card Please upload a copy of your Insurance card. If you do not have this available, please complete the following fields regarding Insurance information.

Add file

Please upload a file

Is Insured Person's address the same as the patient?

Yes No

Insured's Address

City

State

ZIP

Insured's Employer Name

Insured's Occupation

Patient's relationship to insured:

Self Spouse Child Other

Other

Insurance Company Name

Provider Services Phone Number

Secondary

Add Additional Insurance Plan

NOTICE OF PRIVACY PRACTICES

Click here to view

I acknowledge that I have received and reviewed the HIPAA Notice of Privacy Practices (linked above)

Office Policies

This section outlines our office policies and procedures to help you understand what to expect during your time at Woolf Dental. Please take a moment to review this form carefully. Thank you for choosing us for your dental needs!

Please check each box showing that you have read and agree to each policy:

Payment is due at time of service. All insurance and patient portion quotes given verbally or written are estimated based on information available at the time they are diagnosed and are not guaranteed. Patient is responsible for any fees unpaid by the insurance company.

If the insurance company has not fully paid a claim after a reasonable period of time (3 months), the patient will be required to pay the remaining portion.

Patient is responsible to inform Woolf Dental of any changes to their dental coverage at least 48 hours before their appointment. (If applicable)

Any remaining balance on patient’s account must be paid before further treatment is rendered.

If under the age of 18, a parent or legal guardian must be present in the waiting room.

Patient is responsible for confirming their appointment. Failure to do so may result in appointment being given to someone else that is in need.

Arriving late to an appointment may result in needing to be rescheduled. (If you are ever running late, please give us a call).

Patient understands that if they fail to give 24 hours notice or “No Show” to a scheduled appointment, they may be charged a fee dependent on the length of their appointment.

We ask that only the patient receiving treatment be allowed in the operatory during all visits.

Failure to comply with these policies may result in dismissal from our office. If you have any questions about a specific policy, please do not hesitate to ask.

By signing below I acknowledge that I have read and accept the policies for Woolf Dental.

Consent for Services

Click here to view

I acknowledge that I have received and reviewed the Consent for Services (linked above)

Authorization

Patient, Parent, or Guardian or Guarantor's Full Name

Today's Date

Patient's relationship to insured:

Self Spouse Child Parent Guardian Other

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.

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