New Patient Form

Personal Information

Today's Date:

Initial:

Date of Birth:
Age:



Employment



Spouse/Domestic Partner/Parent

Date of Birth:
Age:

Insurance Information

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

Primary Coverage






Secondary Coverage




Insurance Card Front:
Insurance Card Back:
Insurance Card Front:
Insurance Card Back:

Dental History








Oral hygiene techniques(multiple selection allowed):
ToothbrushFlossWaterpickProxabrushOther

Toothbrush type:

Referral form:

Medical History

Are you in good health?

Are you being treated by a physician for any illness or condition?

Have you had any serious illness/operation/hospitalized?

Do you have any allergic reaction to any medications? e.g. Penicillin, Codeine, Aspirin

Is there any family history of any illness/disease, e.g. heart problems, diabetes, cancer

Women: Are you pregnant?

Any medication you had an adverse reaction to

Immune deficiency syndrome(HIV/AIDS)


Please Specify and list all current medications:




Have you taken any long term medications in the past? Prescription or Non-Prescription

Mark if any of the following apply to you

AllergiesAllergy to LatexAnemia/blood disorderArthritisAsthmaBacterial endocarditisBlood transfusionChest painCongestive heart failureDiabetesDrug/Alcohol abuseEmphysemaEpilepsy/SeizuresGlaucomaHeart diseaseHeart murmurHepatitisHigh blood pressureHospitalized for any conditionHyperthyroid/hypothyroid
Kidney diseaseLiver diseaseLow blood pressureMitral valve prolapsePacemakerPhen-fen/redux/pandimin useProlonged bleedingProsthetic heart valveProsthetic jointsPsychiatric treatmentPulmonary shuntRadiation treatmentRheumatic feverScarlet feverShortness of breathStrokeSwollen anklesTuberculosisTumors/CancerUlcers
Venerial diseaseChemotherapyHigh CholesterolMultiple SclerosisAutoimmune diseaseOther (please specify below)SmokerAware of any health change in the past yearAware of any recent weight changeGenerally a nervous personHave you taken or are you taking a Biphosphonate (Fosomax, Boniva, Didrocal, Actonel, Aredia, Zometa)Often exhausted or fatiguedOften thirstyOften unhappy or depressedPresently being treated for illnessUrinating more than six times a dayTaking herbal medicationPostmenopauseTaking birth control pills or hormones

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 hours advance notice. This will allow us time to find you another reservation, ensuring continued optimal care and avoiding a cancellation fee ($85). 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.

Patient's Signature:
Parent/Guardian: