New Patient Forms

New Patient Forms

So we can ensure that we can provide you with the best care possible, please fill out the following private and secure HIPAA compliant form to the best of your abilities.
Patient Information
Full Name*

PrefixFirst NameMiddle NameLast Name
Preferred Name
Date of Birth

MonthDayYear
Gender*
Marital Status*

SingleMarriedOther
Social Security
Occupation
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Type:*
Phone Number*

Area CodePhone Number
Type:
Phone Number

Area CodePhone Number
E-mail*
example@example.com
Welcome to our Practice
How did you hear about our practice?*
Who can we thank for referring you to our practice?
Primary Dental Benefit Information

You can leave this section blank if you have already provided us this information.
Subscriber's Name
Subscriber's Date of Birth

MonthDayYear
Date
Name of Dental Benefit Plan
Relationship of patient to subscriber
Member ID or SSN#
Group #
Employer Name
No Insurance
Upload a photo of your insurance card

Upload a File

Cancelof
Take a photo of your insurance card on your phone
Secondary Dental Benefit Information

You can leave this section blank if you have already provided us this information.
Subscriber's Name
Subscriber's Date of Birth

MonthDayYear
Date
Name of Dental Benefit Plan
Relationship of patient to subscriber
Member ID or SSN#
Group #
Employer Name
Upload a photo of your insurance card

Upload a File

Cancelof
Take a photo of your insurance card on your phone
In case of Emergency
Emergency Contact Name*
Phone Number

Area CodePhone Number
Physician's Name
Phone Number

Area CodePhone Number
Are you being treated by your GP or a Specialist at the moment?*

YesNo
If yes, please give details
Pharmacy*
Address*
Your Medical History
Please click to indicate that you have had the following conditions*

Alzheimers/DementiaAnxietyArthiritisArtificial Heart ValveArtificial jointsAsthmaAtrial fibrillationLung Disorders/DiseaseCancerCerebral palsyChemotherapyChronic PainColitisCrohn's diseaseDepressionDiabetesDysrhythmiaEmphysemaEpilepsy/SeizuresEye ProblemsFatigueFibromyalgiaGastoparesisGERD/Acid RefluxGlaucomaHay FeverHeart (Surgery, Disease, Attacks)Heart DiseaseHeart MurmurHepatitisHerpesHIVHypercholesterolemia- High cholesterolHyperlipidemia- High fat in bloodHypertension-High Blood Pressure HBPHypothyroidism-underactive thyroidHyperthyroidism-overactive thyroidHypotension- Low Blood PressureJoint ReplacementKidney ProblemsLiver DiseaseMesotheliomaMigrainesMitral valve prolapseMultiple SclerosisNasal Obstruction/Deviated SeptumOsteoporosisPacemakerParkinson's diseasePsychiatric/Psychological CareRadiation TherapyRheumatoid autoimmune diseaseSexually Transmitted DiseaseSleep ApneaStrokeTrigeminal neuralgia painNO MEDICAL ISSUESOther
Do you have any other medical conditions not listed above?*

YesNo
If yes, please give details
Has your Physician or Specialist told you that you require taking antibiotics before dental treatment?*

YesNo
Do you smoke cigarettes?*

YesNo
Do you smoke marijuana?*

YesNo
If yes, please give details
Are you pregnant?

YesNo
If yes, how many weeks?
Do you have any allergies to

AcetaminophenAmoxicillin/PenicillinAspirinClindamycinCodeineErythromycinIbuprofenLatexLocal AnestheticMetalSulfaOther
Do you have any adverse reactions and/or allergies to any drugs or medications not listed above?*

YesNo
If yes, please give details
Are you taking any drugs or medications (including vitamins & herb supplements)?*

YesNo
If yes, please write down the name of the medication and reason for taking it. If you have a large list, upload a document or take a photo of your list on your phone below and submit it.
Upload a photo or document of your medication list

Upload a File

Cancelof
Take a photo of your medication list on your phone
Your Dental History
Reason for your dental visit*
Please mark if any of the following is relevant to you

Previous bad experience at the dentistJaw clicks or hurtGrind/clench teethOrthodontic (braces) treatment - Currently [Contact Ortho office to coordinate]Orthodontic (braces) treatment - PreviouslyUse a night guardPeriodontal (gum) treatment or deep cleaningBleeding gums when brushing teeth or flossingBad breathSensitive teeth to hot/coldOther issues
Is there any other concerns about your teeth? If yes, please give details.
Are you interested to see if we could offer any cosmetic procedures to your teeth?*

YesNoUnsure
If yes, which procedures are you particularly interested in?
Previous Dental Office*
How long since your last dental appointment?*
Have you had any dental radiographs in the past year? Our office requires new dental radiographs be taken if your most recent radiographs are over 1 year old.*

YesNoUnsure
Do you need any records transferred?*

Yes - please see belowNo
If Yes, please contact your previous office and sign a Records Release form. Forward records to picachodental@gmail.com before your scheduled reservation to avoid additional charges.
Preferred Communication Method
What is your preferred method of communication?*

TelephoneEmailText
Privacy & Confidential Information
I have confidential medical information that I do not wish to write down. I would prefer to speak to the dentist about this.*

YesNo
I have read the Privacy Policy and understood the policy.*

YesNo
Terms & Conditions
Consent for Treatment:
- I hereby authorize the dentist or designated staff to take radiographs, study models, photographs and other diagnotic aids deemed appropriate by the dentist to make a thorough diagnosis as mutually agree upon by me.
- Upon such diagnosis, I authorize the dentist to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide the appropriate care.
- I agree to be responsible for payment of all services rendered on my behalf and/or on behalf of my dependants. I understand that payment is due at anytime of service unless other arrangements have been made.
Payment for Treatment:

We accept cash, Visa, MasterCard, Discover, American Express and Care Credit.

Care Credit is a private payment program we offer. For additional information please ask one of our representatives at the front desk.

Our fees, when quoted for treatment, will be honored for 90 days. Beyond that, fees may be adjusted to reflect any cost increases.

Should the account become past due and be referred to a collection agency, the undersigned agrees to pay any and all additional costs/fees and/or interest charged by, or as a result of the referral, to a collection agency, In addition, should the account be referred to an attorney for collections, the undersigned agrees to pay any and all attorney’s costs/fees and/or interested charged as a result of the referral.

Insurance Policy:

Most insurance plans do not cover 100% of your cost of treatment. Therefore, you will be expected to pay your deductible and your ESTIMATED co-payment on the day services are rendered. Many variables exist from carrier to carrier (ex: deductibles, annual maximums, allowable fee limitations, non-covered procedures and other restrictions), therefore, we cannot guarantee any estimated charges.

You are responsible for advising our office if you have a change in your insurance coverage prior to your appointment. Your insurance is an agreement between you and the insurance company, ultimately you are responsible for all charges. If for some reason your insurance company has not paid their estimated portion within 60 days from the start of treatment, you are responsible for payment in full at that time. Treatment could be altered if your dental needs change. The patient will be notified of any change(s) in treatment. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates. If your insurance company deems a procedure as not a covered benefit patient is responsible for full payment.

Cancellation Policy:

Patients are seen by reservation, emergencies and walk-ins will be seen as time permits. We respectfully ask that you give us 48 hour notice (2 business days) to reschedule your reservation. If you fail to do so, you will be subject to a $75.00 failed/less than 48 hour notice cancellation reservation fee.

I understand the consent for treatment and policies as stated above.

By my electronic signature below, I agree to the terms and conditions.

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health and I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form. It is my responsibility to inform the dental office of any changes in medical status.
Signature*

Clear
Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.
Relationship to Patient*
Name of signee if other than patient
**In Office Use** Dr. Initial
Should be Empty:

Patient Information

Welcome to our Practice

Primary Dental Benefit Information

Secondary Dental Benefit Information

In case of Emergency

Your Medical History

Your Dental History

If Yes, please contact your previous office and sign a Records Release form. Forward records to picachodental@gmail.com before your scheduled reservation to avoid additional charges.

Preferred Communication Method

Privacy & Confidential Information

Terms & Conditions