DOOL - Patient Information

Patient Information
Today's Date

MonthDayYear
Date
Patient Name

First NameMiddle InitialLast Name
Sex

MaleFemale
Marital Status

MarriedSingleChildOther
Date of Birth

MonthDayYear
Date
SSN#
Drivers License
State
Number
Address

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Best time to call
Email
Text Messaging Opt-In: Please check the box below to give your consent and opt in to receive text messages from our dental office. By opting in, you agree to receive appointment reminders, important updates, and exclusive offers via text message. Standard messaging rates may apply.

I consent and opt in to receive text messages from Scott Dooley, DDS.

Cosmetic Information
Do you like the appearance of your teeth?
Is there anything about your smile that you do not like?
Would you like your teeth to be whiter?
Are all of your teeth in alignment (straight)?
Do you have any missing teeth?
Are any chipped?
Is your bite comfortable when chewing, biting?
Do you have frequent headaches?
Do your gums ever bleed?
Do you have any old fillings or dental treatment that you are unhappy with?
Do you use products such as mints, mouth rinse or chewing gum to help maintain fresh breath?
Are you interested in learning more about professional breath control?
Is there anything else that you would like us to know?

Insurance Information
Name of Insured

First NameLast Name
Insured Birth Date

MonthDayYear
Date
Is the insured a patient?

YesNo
Insured's Address

Street Address

Street Address Line 2

CityState

Zip Code
ID #
Group #
Insured's Employer
Employer's Address

Street Address

Street Address Line 2

CityState

Zip Code
Patient's relationship to insured

SelfSpouseChildOther
Insurance Plan
Insurance Plan's Phone Number

Area CodePhone Number

Consent for Services
To the best of my knowledge, all of the preceding I hereby authorize Dr. Dooley and/or staff to take x-rays, models, photographs and other diagnostic aids deemed appropriate by Dr. Dooley to make a thorough diagnosis of my/my child’s dental needs. Upon such diagnosis, I authorize Dr. Dooley to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care. I agree to the use of anesthetics, sedatives and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.

As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon payment from the patients for the costs incurred in their care, and financial responsibility on the part of each patient must be determined before treatment. All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in full at the time services are performed.

As a courtesy this office will prepare the patient’s insurance forms and accept direct payment from your insurance company. All insurance benefit figures are estimates only. Patients with dental insurance understand that all dental service fees are the responsibility of the patient and the patient is personally responsible for payment of all dental services.

I understand that any fee estimate provided by this office for my dental care will be honored for a period of ninety (90) days from the date of the patient examination.

I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form.

Our practice is dedicated to exceptional care and service. Because many of our patients want specific appointment times during the day, we have adopted guidelines to allow our patients to pre-reserve certain appointments. In order to serve everyone efficiently; we require 48 hour notice for any appointment changes. A $35.00 charge will be assessed for broken and missed appointments without advance notice. Exceptions will be made for emergencies. Thank you for your cooperation and for allowing us to serve all of our patients.
I have read the above conditions of treatment and payment and agree to their content. (Sign Below)*

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Acknowledgement of Receipt of Notice of Privacy Practices

* You May Refuse to Sign This Acknowledgement
I, full name* , have received a copy of this office's Notice of Privacy Practices.
I hereby acknowledge that a copy of this office’s Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions I may have regarding this Notice. (Sign Below)

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Date

MonthDayYear
Date
For Office Use Only

******************
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

_____ Individual refused to sign

_____ Communications barriers prohibited obtaining the acknowledgement

_____ An emergency situation prevented us from obtaining acknowledgement

_____ Other (Please Specify)
Should be Empty:

	Yes	No
AIDS
Allergies
Allergic/Adverse Reaction to Medication or any Substance
Anemia
Arthritis
Artificial Joints
Artificial Heart Valve
Asthma
Blood Disease
Bruise Easily
Cancer
Codeine Allergy
Cold Sores/Fever Blisters
Contact Lenses
Cortisone Medication
Diabetes
Diet (Special/Restricted)
Dizziness
Emphysema
Epilepsy
Excessive Bleeding
Fainting
Glaucoma
Growths
Hay Fever
H. I. V. Positive
Head Injuries
Heart (Attack, Disease, Surgery)
Heart Murmur
Hemophilia
Hepatitis
High Blood Pressure
Jaundice
Kidney Disease
Latex Sensitivity
Liver Disease
Mental Disorders
Mitral Valve Prolapse
Nervous Disorders
Pacemaker
Penicillin Allergy
Psychiatric/Psychological Care
Pregnancy
Radiation Treatment
Respiratory Problems
Rheumatic Fever
Rheumatism
Sinus Problems
Smoke/Chew Tobacco
Stomach Problems
Stroke
Thyroid Problems
Tuberculosis
Tumors
Ulcers
Venereal Disease

Patient Information

Health Information

Health History

Cosmetic Information

Referral Information

Spouse or Responsible Party Information

Employment Information

Insurance Information

Consent for Services

Acknowledgement of Receipt of Notice of Privacy Practices

For Office Use Only