Health History Form

Health History

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

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Address
City
State/Province
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Do you have any of the following diseases or problems?

Check Don't Know if you don't know the answer to the question

If you answer yes to any of the 4 items above, please stop and call us at 970-241-4YES(4937)

Dental Information

Medical Information

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Address
City
State/Province
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Alergies

To all yes responses, specify type of reaction. Are you allergic to or have you had a reaction to:

Please mark your response to indicate if you have or have not had any of the following diseases or problems.

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NOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

New Patient Form

New Patient Forms

Thank you for selecting Yes! Dental for your dental needs. We appreciate the trust and confidence you have placed in our office. Our entire staff is a team dedicated to providing the highest quality dental care and service to our patients. We take great pride in each staff member's training and capabilities. Thank you, and WELCOME

Appointments:

We do our best to keep waiting times to an absolute minimum, we recognize that your time is valuable, but there are times that we see emergency cases and get behind, if this happens and it causes a problem with your schedule then we will gladly reschedule your appointment.

We have a twenty-four hour cancellation fee of $30.00. If you are not able to keep your appointment for any reason, please phone the office at least twenty-four hours in advance. This will enable us to help you schedule another appointment and release your slot to another patient in need. This will also help us keep our cost low and continue to offer affordable dental care.

We require you to confirm your appointment, if we do not receive a confirmation by ten in the morning; we will cancel your appointment and schedule another in your place.

If you miss two appointments we will not schedule you anymore. You will be dismissed from the practice.

Dental Insurance:

As a service to our patients, we will prepare all of the necessary insurance forms. However, we remind you that your policy is an agreement between you, or your employer, and your insurance company. Not between your insurance company and our office.

We can make no guarantee of any estimated coverage. We will do our best to see that you receive your maximum benefits. Please keep in mind that you are responsible for your total obligation should your insurance benefits result in less coverage than anticipated. If you would like to know that your expected coverage will be, we will submit a pretreatment estimate. Your insurer will generally send a detailed response within four to six weeks.

Financial Arrangements:

Payment is expected at the time services are performed. We accept cash, checks, Visa, Master Card, and American Express. Our primary concern is your dentistry and we will be sensitive to your financial circumstances.

HIPPA