New Patient Form Step 1 of 5 - Patient/Insurance Information 20% Patient InformationFirst Name * Required First Last Name * Required Last Phone * RequiredEmail * Required SSN * Required Address * Required Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Sex * RequiredMaleFemaleMarital Status * RequiredSingleMarriedWidowedSeparatedDivorcedBirthdate - must be mm/dd/yyyy format * Required MM slash DD slash YYYY Patient Employer Occupation Work PhoneHow would you like to be notified for upcoming appointments? Email Phone Text Mobile Carrier Insurance InformationAny Dental Insurance Coverage? * RequiredYesNoWho is your carrier? * Required ID number/Social # * Required Person Responsible for Account * Required Relation to Patient Birthdate - must be mm/dd/yyyy format MM slash DD slash YYYY PhoneAddress (if different from patient's) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Patient Dental HistoryPlease check if you have had any of the following: Bad breath Bleeding gums Clicking or popping jaw Food collection between teeth Grinding teeth Loose teeth or broken fillings Periodontal Treatment Sensitivity to hot or cold Sensitivity to sweets or biting Sores or growths in your mouth Frequent headaches Orthodontic work Prolonged bleeding following extractions Pain (joint, ear, side of face) Other If other, please specify: How many times per day do you brush? How many times per day do you floss? If you could change something about your smile or teeth, what would it be?What is the name of your previous dental office? Reason for leaving your previous dental office? PermissionEmergency Contact * Required Emergency Contact Relation * Required Emergency Contact Phone * Required Patient Medical HistoryPhysician * Required Location * Required Date of Last Exam - must be mm/dd/yyyy format MM slash DD slash YYYY Are you under medical treatment now? * Required Yes No Have you ever been hospitalized for any to any surgical operation or serious illness? * Required Yes No Are you taking any blood thinners or aspirin? * Required Yes No Are you taking any medication(s) including non-prescription medicine? * Required Yes No If yes, what medications are you taking? (If you are not able to list them right away, please email/bring a list in.)Do you currently use: Alcohol Tobacco Coffee Are you allergic to, or have had any reactions to any of the following: Local Anesthetic (e.g. Novocain) Aspirin Codeine Hay Fever Latex Penicillin or other Antibiotics Other Allergies: Are you, or think you might be pregnant? * Required Yes No Are you nursing? * Required Yes No Are you taking birth control pills? * Required Yes No Do you have any of the following? Anemia Arthritis Artificial Joints Asthma Cancer Diabetes Dizziness/Fainting Epilepsy/Seizures Glaucoma Heart Condition Heart Murmur Heart Pacemaker Hepatitis A, B, C High/Low Blood Pressure AIDS/HIV Infections Jaundice Kidney Condition Radiation Therapy Respiratory Problem Rheumatic Fever Sinus Trouble STD Stomach Problem Stroke Tumor/Ulcers Other If other, please list: AuthorizationConsent * Required I agree to the below statement.I authorize my insurance company to pay to the dentist or dental group all insurance benefits otherwise payable to me I authorize the use of the signature on all insurance submissions. I understand this practice’s Notice of Privacy Practices written in plain language. This notice provides the usage of Initial disclosure of my health information as protected by HIPAA. I understand this office has the right to alter this privacy in regards to my health information. If changes occur this Initial practice will provide me with a revised notice of the privacy policy upon my request. I instruct the dentist and/or hygienist to deliver the care that, in their professional judgement, can best help me in the Initial restoration of my health.Consent I agree to the below statement.I consent to allow photographs and/or x-rays to be used for demonstrations, marketing material, patient education, etc. Consent * Required I agree to the below statement.I understand that I am financially responsible for all charges whether or not paid by my insurance. I authorize the use of my signature on all insurance submissions. Consent * Required I agree to the below statement.I have answered all questions regarding myself, or my dependent's medical history and present health condition fully and truthfully, including allergies. I also understand if there are any changes in my, or my dependents health I am to inform the doctor at my next appointment. Consent * Required I agree to the below statement.I agree to provide a minimum of 24 hour notice if I need to change my appointment for any reason. I understand if I fail an appointment I may be charged a fee. Failure to show for a second appointment may result in dismissal from the practice. Consent * Required I agree to the below statement.I instruct the dentist to deliver care that, in their professional judgement, is necessary in the restoration of my health once they've been discovered and discussed. Consent * Required I agree to the below statement.State and federal laws require us to maintain the privacy or your health information and to inform you about our privacy practices by providing you with a Notice of Privacy Practices. This form is available online for your convenience, if you prefer a paper copy, please feel free to contact us. Whom may we thank for referring you/ how did you hear about us? * Required Full Name * Required Date - must be mm/dd/yyyy format * Required MM slash DD slash YYYY
