Patient Information
Name
Preferred Name
Phone
Email
Date of Birth
Address
How did you find our office?
Parent/Guardian Information (if applicable)
Name
Date of Birth
Phone
Email
Relationship to Patient
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Parent
Guardian
Conservator
Other
Address
Insurance Information
Insurance Company Name
Insurance Company Address
Insurance Company Phone
Group/Plan Number or Member ID
Sleep/Airway Conditions
Health History
If "Fair" or "Poor", please explain:
Please list all medications and dosage that you are currently taking:
Please list all allergens (including drugs):
Do you require any antibiotics?
Have you had/experienced any of the following?
Any diseases or conditions not mentioned above?
If you answered "yes" to either, when did it happen and what treatment did you receive?
Dental History
Approximately when was the last visit?
Do you take fluoride in any of the following forms?
-- Please Select --
Fluoride tablets or in vitamins
Drinking tap water
Topical application to teeth (toothpaste)
None
Last Date of Use
How frequently do you brush your teeth?
-- Please Select --
Once a day
Twice a day
Three or more times a day
Less than once a day
Rarely/never brush
How frequently do you floss your teeth?
-- Please Select --
Once a day
Twice a day
Three or more times a day
Less than once a day
Rarely/never floss
Have your teeth/face ever been injured?
Have you received any unusual dental or surgical treatment to the mouth?
Are you seeing a dental specialist?
Do you have dental restorations that need to be completed?
Are you currently pregnant?
Have you had/experienced any of the following?
How did you learn about us?
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Search Engines (e.g. Google)
Review Websites (e.g. Yelp)
Referrals / Word of Mouth
Online Advertising
Physical Advertising
Social Media
Publications
Other
What made you decide to work with our office?
May we thank someone for referring you?
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Referring Doctor
One of our valued patients
Other
Name of Individual
Agreements
Patient Responsibilities: We are committed to providing our patients with the best possible care and helping them achieve optimal oral health. Toward these goals, we would like to explain your financial and scheduling responsibilities with our practice.
Insurance Plans: Your dental benefit is a contract between you or your employer and the insuring company. Benefits and payments received are based on the terms of the contract negotiated between you or your employer and the insuring company. We are happy to help our patients with dental benefit plans to understand and maximize their coverage.
Our practice may NOT be a contracted provider with your insurance's network.
If we are a contracted provider with your plan , you are responsible only for your portion of the approved fee as determined by your plan. We are required to collect the patient’s portion (deductible, co-insurance, co-pay, or any amount not covered by the dental benefit plan) in full at time of service. If our estimate of your portion is less than the amount determined by your plan, the amount billed to you will be adjusted to reflect this.
If we are not a contracted provider with your insurance plan , it is your responsibility to verify with the insurance company whether the plan allows patients to receive reimbursement for services from out-of-network providers. If your plan allows reimbursement for services from out-of-network providers, our practice can file the claim with your plan and receive reimbursement directly from the plan if you “assign benefits” to us. In this circumstance, you are responsible and will be billed for any unpaid balance for services rendered upon receipt of payment from the plan to our practice, even if that amount is different than our estimated patient portion of the bill. If you choose to not “assign benefits” to our practice, you are responsible for filing claims and obtaining reimbursement directly from your insurance company and will be responsible for payment to our practice before or at the time of service.
Scheduling of Appointments: We schedule all our patients as promptly as possible and we try our best to stay on schedule to minimize your waiting. However, in rare circumstances, emergency patients may take priority and this may cause delays. Even so, we reserve the doctor's time on the schedule for each patient procedure so we require a prior notice to reschedule an appointment. To serve all patients in a timely manner, we may need to reschedule an appointment if a patient is 15 minutes late or more. Late rescheduling, being late to an appointment, or missing an appointment may require rescheduling and may incur a fee and/or a deposit to reserve future appointments. Refer to our
Practice Policy page for more information.
Authorizations: I understand that the information I have given today is correct to the best of my knowledge. I authorize this dental team to perform any necessary dental services that I may need and have consented to during diagnosis and treatment.
Notice of Privacy Practices
Dental Materials Fact Sheet
Electronic Signature
Today's Date
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