New Patient Form

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.

    Print Health History Form

    Health History Form

    Today's Date*

    PATIENT INFORMATION

    First Name *

    Middle Initial

    Last Name *

    Home Phone

    Cell Phone *

    Work Phone

    Email Address *

    Preferred Method of Contact *

    Mailing Address *

    City *

    State *

    Zip code *

    Date of Birth*

    Sex

    Social Security # (***-**-****)

    Occupation

    Emergency Contact Name*

    Emergency Contact Number*

    How did you hear about us?

    If you are completing this form for another person, what is your relationship to that person?

    Your Name

    Relationship

    Home Phone

    Cell Phone

    DENTAL INFORMATION

    Are your teeth sensitive to cold, hot, sweets or pressure?*

    Have you had any periodontal (gum) treatments?*

    Have you ever had orthodontic (braces) treatment?*

    Have you ever had any problems associated with previous dental treatment?*

    Do you brux or grind your teeth?*

    Do you have sores or ulcers in your mouth?*

    Do you wear dentures or partials?*

    Are you currently experiencing dental pain or discomfort?*

    Chief Complaint*

    Date of your last dental exam

    What was done at that time?

    Date of last dental x-rays

     

    MEDICAL INFORMATION

    Are you currently under the care of a physician?*

    Physician Name

    Physician Phone Number

    Are you in good health?*

    Has there been any change in your general health within the past year?*

    If yes, what condition is being treated?

    Date of last physical exam

    Do you have a history of chemical dependency?*

    Do you use controlled substances (drugs)?*

    Do you use tobacco (smoking, snuff, chew, bidis)?*

    If so, how interested are you in stopping?

    Have you had a serious illness, operation or been hospitalized in the past 5 years?*

    If yes, what was the illness or problem?

    Do you take any blood thinners?*

    Do you take aspirin on a regular basis?*

    Are you taking or have you recently taken any prescription or over the counter medicine(s)?*

    If yes, please list all medications, including vitamins, natural or herbal preparations and/or diet supplements

    WOMEN ONLY

    Are you Pregnant?

    Number of weeks

    Taking birth control pills or hormonal replacements?

    Nursing?

    Have you ever had an orthopedic total joint (hip, knee, elbow, finger) replacement?*

    If yes, date

    If yes, have you had any complications?

    ALLERGIES

    Please mark "Yes" if you are allergic to (or have had a reaction to) the following.

    Local anesthetics

    Aspirin

    Penicillin or other antibiotics

    Barbiturates, sedatives, or sleeping pills

    Sulfa drugs

    Codeine or other narcotics

    Metals

    Latex (rubber)

    Food / Other

    If yes, please specify

    Please mark "Yes" if you have (or have had) any of the following diseases or problems.

    Heart murmur

    Mitral valve prolapse

    Artificial heart valves

    Rheumatic fever

    Cardiovascular disease

    Angina

    Arteriosclerosis

    Congestive heart failure

    Coronary artery disease

    Damaged heart valves

    Heart attack

    Low blood pressure

    High blood pressure

    Congenital heart defects

    Pacemaker

    Rheumatic heart disease

    Abnormal bleeding

    Anemia

    Blood transfusion

    If yes, date

    Hemophilia

    AIDS or HIV infection

    Arthritis

    Autoimmune disease

    Rheumatoid arthritis

    Systematic lupus erythematosus

    Asthma

    Bronchitis

    Emphysema

    Sinus trouble

    Tuberculosis

    Cancer / Chemotherapy / Radiation treatment

    Chest pain upon exertion

    Chronic pain

    Diabetes type I or type II

    Eating disorder

    Malnutrition

    Gastrointestinal disease

    GE Reflux / persistent heartburn

    Ulcers

    Thyroid problems

    Stroke

    Hepatitis, jaundice, or liver disease

    Epilepsy

    Fainting spells or seizures

    Neurological disorders

    If yes, please specify

    Gag Reflex Sensitivity

    Sleep disorder

    Mental health disorders

    If yes, please specify

    Recurrent infections

    If yes, type of infection

    Kidney problems

    Osteoporosis

    Persistent swollen glands in neck

    Severe headaches / migraines

    Severe / rapid weight loss

    STDs / STIs

    ADD

    ADHD

    Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?*

    Do you have any disease, condition, or problem not listed above that you think we should know about?*

    If yes, please explain

    PHARMACY INFORMATION

    Pharmacy Name*

    Pharmacy Phone

    Pharmacy Address

    SIGNATURE

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

    Name of Patient/Legal Guardian *

    Signature of Patient/Legal Guardian *

    Date *

    HIPAA Consent Form

    HIPAA Consent Form

    GENERAL INFORMATION

    Name *

    Date of Birth *

    Mailing Address *

    City *

    State *

    Zip code *

    CONSENT & NOTICE OF PRIVACY PRACTICES

    Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operation.

    Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information.

    We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

    You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting us by phone or email.

    Right to Revoke: You will have the right to revoke this Consent at any time by giving us a written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance of this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

    SIGNATURE

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

    Name of Patient/Legal Guardian *

    Signature of Patient/Legal Guardian *

    Date *

    Insurance Form

    Insurance Form

    GENERAL INFORMATION

    Name *

    Date of Birth *

    PRIMARY DENTAL INSURANCE

    Policy Holder Name (if not patient)

    Relationship to Patient

    If other, please specify

    Name of Employer

    Work Phone

    Address of Employer

    City

    State

    Zip code

    Policy Holder Date of Birth

    Policy Holder Social Security # (***-**-****)

    Insurance Company (State)

    Member ID

    Insurance Group #

    Effective Date

    SECONDARY DENTAL INSURANCE

    Policy Holder

    Policy Holder Name (if not patient)

    Relationship to Patient

    If other, please specify

    Name of Employer

    Work Phone

    Address of Employer

    City

    State

    Zip code

    Policy Holder Date of Birth

    Policy Holder Social Security # (***-**-****)

    Insurance Company (State)

    Member ID

    Insurance Group #

    Effective Date

    Assignment of Benefits & Authorization to Release Information

    If I am entitled to benefits under Medicare, Medicaid, or any insurance policy or other health benefit plan (covering me or anyone legally responsible for me), in consideration of services provided to me, I assign, transfer and convey the benefits payable under such program, policy or plan for services rendered to me. I authorize payment of these benefits directly, with such benefits being applied to my bill. I understand and acknowledge that this assignment does not relieve me of financial responsibility for charges incurred by me or anyone on my behalf, and I hereby acknowledge responsibility for and agree to pay charges not paid under this assignment, including any coinsurance amounts, deductibles, Durable Medical Equipment, and any charges for service deemed to be non-covered, not pre-certified, or not pre-authorized by my insurance plan.

    Initial *

    I give my consent for examination and treatment.

    Initial *

    I authorize the release of information including the diagnosis, records, examination, treatment, radiology, and claims of information.

    This information may be released to

    SIGNATURE

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

    Name of Patient/Legal Guardian *

    Signature of Patient/Legal Guardian *

    Date *