New Form About You First Name Last Name I prefer to be called I am (Please provide your gender) MaleFemale 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) SingleMarriedDivorcedWidowedSeparated Home Phone Cell Phone Work Phone Ext Your email Employer How Did you Hear About us MagazineYellow PagesOur WebsiteFamilyFriendAnother PatientOther 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 YesNo 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 YesNo 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? YesNo 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 YesNo Alcohol/Drug Abuse YesNo Anemia YesNo Arthritis YesNo Ashthma YesNo Artificial Bones/Joints YesNo Blood Transfusion YesNo Cancer / Chemotherapy YesNo Colitis YesNo Congenital Heart Defect YesNo Diabetes YesNo Difficulty Breathing YesNo Emphysema YesNo Fainting Spells YesNo Epilepsy YesNo Frequent Headaches YesNo Glaucoma YesNo Hay Fever YesNo Heart Murmur YesNo Heart Attack YesNo Heart Surgery YesNo Herpes/Fever Blisters YesNo High Blood Pressure YesNo Hemophilia YesNo Hospitalized (any Reason) YesNo Kidney Problems YesNo Latex Sensitivity YesNo Liver Disease YesNo Low Blood Pressure YesNo Pacemaker YesNo Mitral Valve Prolapse YesNo Psychiatric Problems YesNo Radiation Treatment YesNo Rheumatic/Scarlet Fever YesNo Seizures YesNo Shingles YesNo Sickle Cell Disease YesNo Sinus Problems YesNo Stroke YesNo Thyroid Problems YesNo Tuberculosis YesNo Ulcers YesNo Venereal Disease YesNo List any medical condition(s) you have ever had If yes, please list each: Please list any other drugs you are allergic to Are you taking any prescription or over the counter drugs? If yes, please list Your current physical health is: GoodFairPoor Are you currently under a physician's care? YesNo Are you allergic to any of the following? AspirinCodeineDental AnestheticsErythromycinLatexPenicillinTetracyclineOther Are you taking birth control pills? YesNo Are you pregnant? YesNo Are you nursing? YesNo 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? YesNo Are you currently in pain? YesNo Your current dental health is: GoodFairPoor How many times per week do you floss? How many times per day do you brush? Are you happy with your smile? YesNo Do your gums ever bleed? YesNo Are any of your teeth sensitive? YesNo Have you noticed any mouth odors? YesNo Have your parents experienced gum disease or tooth loss? YesNo Does food get caught between your teeth? YesNo Do you smoke/chew tobacco? YesNo Have you noticed any loose teeth or change in bite? YesNo Accurate Information Provided & Payment * By checking this box I assert that the information that I have provided today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental service that I may need during diagnosis and treatment with my informed consent. I also understand that payment is due in full at the time of treatment unless prior arrangements have been made and approved. Privacy Act Acknowledgement * By checking this box I acknowledge that I have read the Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy. 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
