New Patient Forms

Snow Dental
PATIENT INFORMATION
Welcome to our office! To assist us in serving you, please complete the following confidential form.
Patient's name
Preferred name
Birth date

MonthDayYear
Date
Home phone
Cell phone
Email
example@example.com
Address

Mailing address

Street Address Line 2

CityState

Zip
Employer
Occupation
Emergency contact name
Emergency Contact Number
Relationship_
Whom may we thank for referring you to our office?
DENTAL INSURANCE INFORMATION:

Not covered by dental insurance
Are you the insurance subscriber?

YesNo
Insurance subscriber's Name
Insurance subscriber's birth date

MonthDayYear
Date
Insurance subscriber's Employer.
Dental Insurance Co
Group #
ID #
MEDICAL HEALTH HISTORY
(PLEASE CHECK ANY THAT APPLY)
Heart Problems

High blood pressureHeart murmurHeart valve problemTaking heart medicationRheumatic feverPacemakerHeat attackHeart Surgery
Heart attack date:

MonthDayYear
Date
History of heart surgery Date:

MonthDayYear
Date
Bone or Joint Problems

ArthritisJoint Replacement
Joint Replacement Date

MonthDayYear
Date
Intestinal Problems

UlcersSpecial diet
Allergy problems

Hay feverSinus problemsAsthmaTaking allergy medications
Tobacco use

SmokingSmokeless (chewing, dipping, vaping, ect.)Past use
Past use date

MonthDayYear
Date
Do any of the following apply?

PregnantNursingType I or type II diabetesFamily history of diabetesHistory of drug or alchohol abuseFainting spells, seizures or epilepsyRespiratory disease tuberculosis, COPD,Thyroid problemsCancer or tumorStroke
Cancer / Stroke Date

MonthDayYear
Date
Has a physician recommended antibiotic premedication for your dental appointments?

YesNo
Have you had surgery or been hospitalized in the last year?

YesNo
Blood problems

Easy bruisingAbnormal BleedingBlood diseaseBlood transfusionHIV-positive/AIDS
Allergies
Are you allergic to, or have you reacted adversely to any of the following?

PenicillinSulfaLocal anestheticsCodeine or other narcoticsBarbiturates, sedatives, or sleeping pillsTaking allergy medicationAspirin, Acetaminophen, or IbuprofenMetalsUlcersLatexOther:
Other Allergies
List of current medications and those taken within the last year
Name and phone number of your physician.
DENTAL HEALTH HISTORY
How long has it been since your last cleaning and exam?
How often do you brush?
How often do you floss?
Have you ever noticed slow-healing sores in or around mouth?

YesNo
Are your teeth sensitive to the following?

HotColdSweetsPressure
Do you have dry mouth?

YesNo
Have you had problems with previous dental treatment?

YesNo
Are you apprehensive about dental treatment?

YesNo
Are you satisfied with the appearance of your teeth?

YesNo
Would you like information on whitening your teeth?

YesNo
Do you avoid brushing part of your mouth due to pain?

YesNo
Do you gag easy?

YesNo
Do you wear partials or dentures?

YesNo
Do you have difficulty chewing or do you chew on only on side of your mouth?

YesNo
Do your gums feel swollen, tender or bleed?

YesNo
Do you wear a night guard?

YesNo
Do you have airway/ sleep issues or have you been diagnosed with sleep apnea?

YesNo
Do your snore?

YesNo
Do clench or grind your teeth?

YesNo
Are you aware of an uncomfortable bite?

YesNo
Do you have difficulty opening your mouth?

YesNo
If you have x-rays from a previous dentist please have them emailed to snowdentaloffice@gmail.com.
Signature of patient or guardian:

Clear
Date:

MonthDayYear
Date
PATIENT CONSENT FORM (HIPAA)

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:

- Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment)

- Obtaining payment from third party payers (e.g. my insurance company)

- The day-to-day healthcare operations of your practice

I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.

I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.

I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.
Signature

Clear
Date

MonthDayYear
Date
Appointment Cancellation/Reschedule Office Policy

When our office books your appointment, we are setting aside a dedicated chair and time slot just for you. We only ask that if you must reschedule your appointment, that you please provide us with at least 24hr notice. This courtesy makes it possible to give your reserved time slot to another patient who is on a waiting list or a patient with a dental emergency.

There is a charge of $75 for a same day cancellation or failing to show for a scheduled appointments, unless a 24hr notice is given.

I fully understand that I need to give the office 24hr notice to cancel or reschedule all appointments to avoid a $75 canceled/failed appointment fee.
Signature

Clear
Date

MonthDayYear
Date

Snow Dental

PATIENT INFORMATION

MEDICAL HEALTH HISTORY

(PLEASE CHECK ANY THAT APPLY)

Allergies

DENTAL HEALTH HISTORY

If you have x-rays from a previous dentist please have them emailed to snowdentaloffice@gmail.com.