New Patient Form

    About You

    First Name
    Last Name
    I prefer to be called
    I am (Please provide your gender)
    Date Of Birth
    Age (Please provide your age)
    SS# (Please provide your SS# in the form XXXX -XX-XXXX)
    Drivers Licenses
    Street Address
    Street Address Line 2
    City
    State/Province
    ZIP / Postal Code
    I am (Please provide martial Status)
    Home Phone
    Cell Phone
    Work Phone
    Ext
    Your email
    Employer

    How Did you Hear About us

    Spouse Info

    First Name
    Last Name
    His/Her Employer
    His/Her Home Phone
    His/Her Cell Phone
    His/Her Work Phone
    His/Her Date of Birth
    SSN# (Please provide your SS# in the form XXXX-XX-XXXX)
    His/Her Driver's License #

    Billing Info

    Person Responsible for account *
    Street Address
    Street Address Line 2
    City
    State/Province
    ZIP / Postal Code
    Billing Cell Phone
    Billing Phone
    Billing Work Phone
    Driver's License #
    His/Her Employer
    Date Of Birth Responsible party
    SSN# (Please provide your SS# in the form XXXX-XX-XXXX)
    Relation

    Primary Dental Insurance Section

    Do you have Primary Dental Insurance
    Insurance Company Name
    Insurance Company Phone no
    Street Address
    Street Address Line 2
    City
    State/Province
    ZIP / Postal Code
    Group # (Policy #)
    Insured Name
    Relationship to patient
    Insured's Date of Birth
    Insured's Employer
    Insured's SS#
    Insured's Id#

    Secondary Dental Insurance Section

    Do you have Secondary Dental Insurance
    Insurance Company Name
    Insurance Company Phone no
    Street Address
    Street Address Line 2
    City
    State/Province
    ZIP / Postal Code
    Group # (Policy #)
    Insured Name
    Relationship to patient
    Insured's Date of Birth
    Insured's Employer
    Insured's SS#
    Insured's Id#

    Emergency Contact

    Emergency First Name
    Emergency Last Name
    Relationship
    Emergency Contact Home Phone No
    Emergency Contact Cell Phone *
    Emergency Contact Work Phone
    Relative's First Name
    Relative's Last Name
    Relationship to you
    Relative's Home Phone
    Relative's Cell Phone *
    Relative's Work Phone

    Medical History

    Do you have personal physician?
    Physician's First name
    Physician's Last Name
    Physician's Phone
    Last Date Visited

    Have you ever had any of the following medical problems or diseases?(Place a check next to items to to indicate "yes")
    Abnormal Bleeding
    Alcohol/Drug Abuse
    Anemia
    Arthritis
    Ashthma
    Artificial Bones/Joints
    Blood Transfusion
    Cancer / Chemotherapy
    Colitis
    Congenital Heart Defect
    Diabetes
    Difficulty Breathing
    Emphysema
    Fainting Spells
    Epilepsy
    Frequent Headaches
    Glaucoma
    Hay Fever
    Heart Murmur
    Heart Attack
    Heart Surgery
    Herpes/Fever Blisters
    High Blood Pressure
    Hemophilia
    Hospitalized (any Reason)
    Kidney Problems
    Latex Sensitivity
    Liver Disease
    Low Blood Pressure
    Pacemaker
    Mitral Valve Prolapse
    Psychiatric Problems
    Radiation Treatment
    Rheumatic/Scarlet Fever
    Seizures
    Shingles
    Sickle Cell Disease
    Sinus Problems
    Stroke
    Thyroid Problems
    Tuberculosis
    Ulcers
    Venereal Disease
    List any medical condition(s) you have ever had
    If yes, please list each:
    Please list any other drugs you are allergic to
    Your current physical health is:
    Are you currently under a physician's care?
    Are you allergic to any of the following?
    Are you taking birth control pills?
    Are you pregnant?
    Are you nursing?

    Dental History

    Date of last cleaning
    Date of last dental visit
    What was done during your last visit?
    What is the reason for your visit today?
    How often do you have dental exams?
    Do you need to be pre-medicated before you receive your dental treatment?
    Are you currently in pain?
    Your current dental health is:
    How many times per week do you floss?
    How many times per day do you brush?
    Are you happy with your smile?
    Do your gums ever bleed?
    Are any of your teeth sensitive?
    Have you noticed any mouth odors?
    Have your parents experienced gum disease or tooth loss?
    Does food get caught between your teeth?
    Do you smoke/chew tobacco?
    Have you noticed any loose teeth or change in bite?
    Accurate Information Provided & Payment *
    Privacy Act Acknowledgement *
    Privacy Policy

    LATE TO APPOINTMENT POLICY

    If you are an established patient and you arrive 15 minutes late or more to your appointment, you will likely be asked to reschedule unless the Dentist's schedule can still accommodate you. Priority will be given to the patients who arrive on time and you may have to be worked in between them. This may mean you will have a considerable wait. If this is not convenient for you, you may choose to reschedule. One or two late patients cause the entire daily schedule to fall behind. This is an inconvenience to everyone. We strive to see every patient as close to their appointment time as possible. Likewise if you are a new patient and you arrive at the scheduled appointment time and not early to complete your forms as instructed and it takes more than 15 minutes to complete the forms and the registration process, you may also be asked to reschedule. We ask that you please be courteous Of your provider's valuable time and attention. The Dentist, office staff, as well as your fellow patients will thank you.

    MISSED APPOINTMENT "NO-SHOW" SAME DAY CANCELLATION POLICY

    While we make every effort to provide a reminder call at least 24 hours before your appointment, this is a courtesy only and it is your responsibility to remember you have an appointment. We charge a missed appointment fee to patients who do not keep their scheduled appointment time or who cancel less than 24 hours in advance. For a 15 or 30 minute appointment, the fee is $35. If this should happen more than twice, a $55 charge will be incurred for the third incident. If the missed appointment is for a procedure, the fee will be $50. All fees must be paid before a new appointment can be scheduled. After three (3) missed appointments, the practice may at its discretion choose to discontinue your care.


    Signature