Patient Forms

Patient Information

Today's Date

First Name

Middle Name

Last Name

Preferred Name

Date of Birth

Address

Street Name

City

State

Zip

Home Phone

Include area code

Business/Cell Phone

Include area code

Cell Phone

Include area code

SS# or Patient ID

Email

May we confirm your appointments by text?

Yes

No

Whom may we thank for referring you?

Employer

Employer Address

Street Name

Employer City

Employer State

Employer Zip

Patient or Spouse Information

Name

Date of Birth

Home Phone

Include area code

Business/Cell Phone

Include area code

SS# or Patient ID

Employer

Dental Insurance Information

Our oﬃce will do everything possible to help you understand and make the most of your dental insurance. We do accept insurance beneﬁts as partial payment for treatment along with your payment of the estimated patient portion cost. You are responsible for all fees and changes for your account. Please be assured that our staﬀ will do all we can to help you receive maximum reimbursement from your insurance company.

Primary Insurance Carrier

Subscriber's Name

Date of Birth

Subscriber's Number

ID Number

Group Number

Insurance Phone #

Secondary Insurance Carrier

Subscriber's Name

Date of Birth

Subscriber's Number

ID Number

Group Number

Insurance Phone #

Dental History

How long has it been since last dental visit?

Date of last dental x-rays

Are you currently in pain?

Yes

No

Don't Know

Are you having any problems now?

Yes

No

Don't Know

What?

Have you had any periodontal (gum disease) therapy?

Yes

No

Don't Know

Do your gums bleed or feel tender?

Yes

No

Don't Know

Are any teeth sensitive to hot, cold, sweets or pressure?

Yes

No

Don't Know

Do you like the appearance of your teeth?

Yes

No

Don't Know

Would you like to change the shape, size, or color?

Yes

No

Don't Know

Are you aware of grinding or clenching your teeth?

Yes

No

Don't Know

Do you have frequent headaches, earaches, or sore jaws?

Yes

No

Don't Know

Do you have any loose, tipped or shifting teeth?

Yes

No

Don't Know

Have you ever had orthodontic treatment (braces)?

Yes

No

Don't Know

Do you have missing teeth that have not been replaced?

Yes

No

Don't Know

Do you have problems with teeth or ﬁllings breaking?

Yes

No

Don't Know

Do you wear dentures (partials or full)?

Yes

No

Don't Know

How long have you had them?

Are you interested in permanent replacements?

Yes

No

Don't Know

Have you had any bad dental experiences in the past?

Yes

No

Don't Know

If yes, please explain

Have you had any adverse reactions to drugs used in dentistry?

Yes

No

Don't Know

If yes, please explain

How many times a week do you ﬂoss?

How many times a day do you brush?

Types of bristles?

Hard

Medium

Soft

Thank you for choosing us to meet your dental needs. Our commitment to quality dental care for you is equal to our commitment to customer service. Our staff is here to assist you in any way we can. Please let us know if you have any questions or concerns.

Medical Information

Primary Care Physician

Phone

Include area code

Please CHECK any/all of the medical conditions you currently have or have had in the past:

List any DRUGS/MEDICATIONS you are currently taking:

List any ALLERGIES to Drugs, Medications, or Anesthetics:

Please list any other MEDICAL CONDITIONS not listed above:

General Consent

Thank you for choosing our oﬃce for your dental care. We will work with you to help you achieve excellent oral health. While recognizing the beneﬁts of a pleasing smile and teeth that function well, you should be aware that dental treatment, like treatment of any other part of the body, has some inherent risks. These are seldom great enough to oﬀset the beneﬁts of treatment, but should be considered when making treatment decisions.
Beneﬁts of dental treatment can include: relief of pain, the ability to chew properly, and the conﬁdence and social interaction that a pleasing smile can bring. Nonetheless, there are some common risks associated with virtually all dental procedures, including:

• Drug or chemical reaction. Dental materials may trigger allergic or sensitivity reactions.

• Long-term numbness (paresthesia). Local anesthetic, or its administration, while almost always adequate to allow comfortable care, can result in transient, or in rare cases, permanent numbness.

• Muscle or joint tenderness. Holding one’s mouth open can result in muscle or jaw joint tenderness, or in a predisposed patient, precipitate in a TMJ disorder.

• Sensitivity in teeth or gums, infection or bleeding.

• Swallowing or inhaling small objects.

While we follow procedural guidelines that most often lead to a clinical success, just like any other pursuit in health care, not everything turns out the way it is planned. We will do our best to insure that it does. Please feel free to ask questions in regard to all dental procedures that are recommended to you.

Missed Appointment Policy

Unforeseen events sometimes cause missing an appointment. If you need to cancel or reschedule an appointment, we respectfully request notiﬁcation at least 24 hours prior to your appointment. Lack of suﬃcient notiﬁcation may result in a Missed Appointment Fee being charged to your account.

Financial Policy

We strongly believe that all patients deserve the ﬁnest dental care that we can provide. You beneﬁt from the high standards we have set for ourselves to deliver the utmost quality of dental treatment available. Accordingly, we have prepared this information to advise you of our ﬁnancial policy.

PAYMENT IS DUE IN FULL AT THE TIME OF SERVICE

For your convenience, our oﬃce oﬀers the following methods of payment:

Cash
Check
Visa
Master Card
Discover
American Express

For extended payment options, our oﬃce oﬀers:
Care Credit - Up to 12 months interest free: application required
Applications available at our oﬃce, online at www.carecredit.com or by phone at 1-800-365-8295

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

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental oﬃce of any changes in my medical status. I will not hold the dentist or dental staﬀ responsible for any errors or omissions that I may have made in the completion of this form.

I have read and understand the statements on this page.

Typed Signature

Date

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New Patient Form

Patient Information

Patient or Spouse Information

Dental Insurance Information

Dental History

Medical Information

General Consent

Missed Appointment Policy

Financial Policy

PAYMENT IS DUE IN FULL AT THE TIME OF SERVICE

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

HIPPA