New Patient Form- PDF

New Patient Information
Today's Date*

MonthDayYear
Date
Name*

PrefixFirst NameLast Name
Address*

Street Address

CityState / Province

Postal / Zip Code
Phone Number (better number for text communication)*
Please enter a valid phone number.
Email*
example@example.com
Birthdate*

MonthDayYear
Date
Age*
Social Security Number*
We respect your decision not to provide your social security number- then please put 111-11-1111. If your SSN, however, is the only way to verify your dental insurance, we cannot verify or bill your insurance for any visit.
Driver's License Number
Occupation
Employer name
Work address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work phone
Please enter a valid phone number.
Responsible party if patient is a minor
College attending
Spouse/Domestic Partner/Parent Information

If your dental insurance is through someone else
Name of Spouse/Domestic Partner/Parent
Birthdate

MonthDayYear
Date
Age
Social Security Number
Insurance Information- Primary

If you have dental insurance, please complete the following and apprise us as any changes occur in your coverage
Employee Name

First NameLast Name
Employer
Insurance Company
Group Number
Policy Number
Employee SSN if not given above
Please upload the photo of insurance card- front and back

Cancelof
Insurance Information- Secondary
Employee Name

First NameLast Name
Employer
Insurance Company
Group Number
Policy Number
Assignment & Release
I recognize that I am financially responsible for any services rendered to me at this office. Treatment fees will be presented prior to treatment. Payment in full is appreciated at the time of service. We accept cash, credit cards, and checks. Returned checks will have a $35.00 bank charge applied to the patient account. As a special service to me, insurance claims may be prepared and submitted on my behalf. I hereby authorize this office to release any information to my insurance company that is needed for the filing of my claims. Changes or additions to your insurance must be provided at each appointment for proper insurance submission. We will be unable to resubmit insurance claims due to inaccurate information provided or on file.

Appointments
A scheduled appointment in our practice is considered a confirmation of your reserved time. If you need to change your future appointment, we kindly request 72 BUSINESS hours advance notice. This will allow us time to find you another reservation, ensuring continued optimal care and avoiding a cancellation fee ($125). Three cancellations may result in dismissal from our care, because it compromises our ability to effectively serve your periodontal needs. Thank you for appreciating our appointment policy

Confidentiality
I have been informed of this office’s Privacy Policies and have been instructed as to the location of the office wide policy on display so that I may review the policy at my discretion. I also am aware that a copy of these policies are available to me in print if requested. I permit communication between my doctors, dentists, and family members / guardians as is deemed necessary for successful treatment outcomes.

Insurance
Our office has always been happy to work with patients covered by dental insurance. We think insurance is a great incentive to maintain a vital level of dental health. It is extremely rare that a dental plan that covers 100% of our fees. Here's why. The fees we charge for dental services are the same for every patient, insured or not. A given insurance policy, however, is based on a fixed fee schedule—"usual and customary"—that may have nothing to do with the real world. Dentistry has changed very quickly, insurance fee schedules have not. After all, insurance companies are profitable businesses, not dental benefactors. Further, insurance companies reimburse you an amount they figure is commensurate with average quality dentistry in an average office with an average staff, "average" falling somewhere between the best dentistry and the worst dentistry. Well, we have a better opinion of our services. Our belief is, and always has been, that the style and quality of our dentistry had better be the best. We're happy to help you with any insurance questions you have. We'll go over your policy with you, try to maximize your benefits, and request a predetermination of benefits to let you know what your insurer will pay. Please remember your insurer dictates your coverage—we don't.
Signature*

Clear
Date*

MonthDayYear
Date
Dental History
Referred by*
Current Dentist*
How long have you been with the current dentist?*
Any prior scaling and root planing (deep cleaning)? If so, when?*
Any family history of gum disease?*
When was you last cleaning*
How many cleanings per year?*
Have you had recent xrays? When was it?*
Any prior periodontal surgery?*
Oral hygiene techniques:*

Manual toothbrushElectric toothbrushFlossWaterpickOther
Please upload the photo of Referral Form you received from the referral dentist

Cancelof
PHARMACY INFORMATION
Pharmacy name*
Pharmacy Address (As much information as possible)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pharmacy phone number*
Please enter a valid phone number.
MEDICAL HISTORY
Primary physician*
How long?
Specialty
Office address*
Phone number*
Last physical exam
Last blood work-up
Emergency contact person*
Emergency person's phone number*
Allergy/Adverse reaction to any of these medications?

AspirinErythromycinCodeineDental anestheticsPenicillinTetracyclineSedatives/sleeping pillsOther (list)

Do you have or have you ever had *

	Yes	No
Head or neck injuries
Sensitive Teeth
Difficulty chewing
Clenching or grinding
Trouble opening or closing your mouth
Prolonged bleeding after extractions
Orthodontic treatment (braces)
Periodontal disease
Problems with the TMJ (jaw joint)
Do you have an occlusal guard or night guard
If you have an occlusal or night guard, do you wear it

Heart Do you have or have you ever had *

	Yes	No
Allergies (rash, hives, hayfever)
Allergies to latex
Anemia/blood disorder
Arthritis
Asthma
Bacterial endocarditis
Autoimmune Disease
Bacterial Endocarditis
Blood Transfusion
Chemotherapy
Chest Pain
Congestive Heart Failure
Diabetes
Drug/Alcohol Abuse
Emphysema
Epilepsy/Seizures
Glaucoma
Heart Disease
Heart Murmur
Hepatitis
High Cholesterol
High Blood Pressure
Hospitalization
Hyperthyroid/Hypothyroid
HIV/AIDS (Please specify Tcell count and Viral load below)
Kidney Disease
Liver Disease
Low Blood Pressure
Mitral Valve Prolapse
Multiple Sclerosis
Pacemaker
Phen-fen/redux/pandimin use
Prolonged Bleeding
Prosthetic Heart Valve
Prosthetic Joints
Psychiatric Treatment
Plumonary Shunt
Radiation treatment
Rheumatic Fever
Scarlet Fever
Shortness of Breath
Stroke
Swollen Ankles
Tuberculosis
Tumor/Cancer
Ulcers
Venereal Disease
Other

Are you*

	Yes	No
A smoker
Aware of any health changes in the past year
Aware of any recent changes in your weight
Generally a nervous person
Taking Bisphosphonates (Fosamax, Boniva, Didrocal, Actonel, Aredia, Zometo
Often exhausted and fatigues
Often thirsty
Often unhappy or depressed
Presently being treated for an illness
Urinating more than six times a day
Taking herbal medication
Postmenopause
Pregnant
Taking birth control or hormones
Taking any medications (Please list below)

Tcell count
Viral load
Please explain fully any "Yes" answers above
Please list all medications you are taking (including vitamins, aspirin, etc)
If there are any changes in my medical condition or history I will notify the dentist or your office. *

Clear
Date*

MonthDayYear
Date
Doctor
Should be Empty:

New Patient Information

Spouse/Domestic Partner/Parent Information

Insurance Information- Primary

Insurance Information- Secondary

Dental History

PHARMACY INFORMATION

MEDICAL HISTORY