New Patient Forms

Patient Information - Step 1 of 7

Patient Information

Patient Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone Number *

Cell Phone Number

Work Phone Number

Email *

Date of Birth *

Age *

Patient Sex / Gender *

Male
Female

Contact Preferences for Appointment Reminders *

Email
Text
Phone

Name of Spouse

First

Last

Immediate Family Members?

Responsible Party

Is the patient above also the Responsible Party? *

Payment / Cancellation Policies

Please help us keep the office running smoothly and efficiently. We make every effort to stay on schedule for your benefit and convenience. In return, we respectfully ask patients to fulfill scheduled appointments and be prompt.

Our standard office policy regarding appointments is as follows:

As a courtesy, we attempt to remind patients by telephone three business days prior to an appointment and by text and email 2 days before an appointment. If we are unable to contact you, your appointment card will serve as the confirmation of your appointment and implies you are obligated to be present. That time has been reserved especially for you.

If you need to change your appointment, please contact the office at least 2 business days prior to the appointment scheduled. This will alleviate any late charge that will normally incur. We understand there are certain circumstances that prohibit you from doing this. Exceptions to this rule can be determined on an individual basis according to circumstances.

Insurance Policy

Thank you for taking the time to educate yourself on your particular insurance plan benefits. It is important that you understand your benefits and our office policy.

Dental insurance companies do not intend for their plans to cover all expenses. Their plans serve only as an aid toward acquiring better care.

The amount your plan pays is determined by how much you or your employer paid for the plan. The less that is paid for the insurance, the less you benefit. Insurance benefits packages vary from company to company, and we will gladly assist you with your insurance carrier before treatment.

Please understand that NOT ALL procedures are covered benefit in your plan. We will make every effort to know what your plan covers prior to the beginning treatment but ultimately it is your responsibility to know what is covered under your plan.

We require your application deductible plus your out-of-pocket costs at the time of service.

Some insurance companies tell their clients that "fees are above the usual and customary fees" rather than saying that "their insurance benefits are too low." In our office we do not view our patients as "usual and customary", but as quality people who expect quality dentistry. Remember, your insurance benefit is limited by what your employer pays for the plan less the profits of the insurance company.

Billing Policy

We process all patient accounts through First Pacific Corporation, which states the following explanation of late and finance charges. Late Charge: If your minimum payment is not received by the due date you may be assessed a late payment charge. The amount of the late payment charge to be assessed is the maximum amount authorized under the laws of the state of your domicile. In most states, the late charge will be $5.00 or 5% of the past due minimum payment, whichever is greater with a maximum of $20.00. Finance Charge: The periodic finance rate is 1.25% monthly with a minimum of $1.00 being imposed.

I have read, understand and agree to the above office policies.

I understand that I am fully responsible for all fees of the services rendered, regardless of insurance coverage.

I understand that my estimated out-of-pocket costs and deductible is due at the time of service.

Signature of Patient/ Account Holder, Parent or Legal Guardian *

By typing your full name above, you are consenting to signing this document electronically.

Date Signed *

	Yes	No
Heart Disease	YesHeart Disease Yes	NoHeart Disease No
High Blood Pressure	YesHigh Blood Pressure Yes	NoHigh Blood Pressure No
Low Blood Pressure	YesLow Blood Pressure Yes	NoLow Blood Pressure No
Joint Replacement	YesJoint Replacement Yes	NoJoint Replacement No
Bleeding Problems	YesBleeding Problems Yes	NoBleeding Problems No
Heart Attack	YesHeart Attack Yes	NoHeart Attack No
Rheumatic Fever	YesRheumatic Fever Yes	NoRheumatic Fever No
Mitral Valve Prolapse	YesMitral Valve Prolapse Yes	NoMitral Valve Prolapse No
Cancer	YesCancer Yes	NoCancer No
Radiation Treatment	YesRadiation Treatment Yes	NoRadiation Treatment No
Asthma / Emphysema	YesAsthma / Emphysema Yes	NoAsthma / Emphysema No
Tuberculosis	YesTuberculosis Yes	NoTuberculosis No
Liver Disease	YesLiver Disease Yes	NoLiver Disease No
Anemia	YesAnemia Yes	NoAnemia No
Cochlear Implant	YesCochlear Implant Yes	NoCochlear Implant No
Stroke	YesStroke Yes	NoStroke No
Epilepsy	YesEpilepsy Yes	NoEpilepsy No
Venereal Disease	YesVenereal Disease Yes	NoVenereal Disease No
Positive HIV/AIDS	YesPositive HIV/AIDS Yes	NoPositive HIV/AIDS No
Hepatitis	YesHepatitis Yes	NoHepatitis No
Fainting	YesFainting Yes	NoFainting No
Ulcers	YesUlcers Yes	NoUlcers No
Psychiatric Treatment	YesPsychiatric Treatment Yes	NoPsychiatric Treatment No
Sinus Problems / Allergies	YesSinus Problems / Allergies Yes	NoSinus Problems / Allergies No
Thyroid Disease	YesThyroid Disease Yes	NoThyroid Disease No
Diabetes	YesDiabetes Yes	NoDiabetes No
Arthritis	YesArthritis Yes	NoArthritis No
Kidney Disease	YesKidney Disease Yes	NoKidney Disease No
Bisphosphonate Therapy	YesBisphosphonate Therapy Yes	NoBisphosphonate Therapy No
Sleeping Disorder	YesSleeping Disorder Yes	NoSleeping Disorder No

	0 = I would never doze	1 = I have a slight chance of dozing	2 = I have a moderate chance of dozing	3 = I have a high chance of dozing
Sitting and reading	0 = I would never dozeSitting and reading 0 = I would never doze	1 = I have a slight chance of dozingSitting and reading 1 = I have a slight chance of dozing	2 = I have a moderate chance of dozingSitting and reading 2 = I have a moderate chance of dozing	3 = I have a high chance of dozingSitting and reading 3 = I have a high chance of dozing
Sitting inactive in a public place (e.g. a theatre or a meeting)	0 = I would never dozeSitting inactive in a public place (e.g. a theatre or a meeting) 0 = I would never doze	1 = I have a slight chance of dozingSitting inactive in a public place (e.g. a theatre or a meeting) 1 = I have a slight chance of dozing	2 = I have a moderate chance of dozingSitting inactive in a public place (e.g. a theatre or a meeting) 2 = I have a moderate chance of dozing	3 = I have a high chance of dozingSitting inactive in a public place (e.g. a theatre or a meeting) 3 = I have a high chance of dozing
As a passenger in a car for an hour without a break	0 = I would never dozeAs a passenger in a car for an hour without a break 0 = I would never doze	1 = I have a slight chance of dozingAs a passenger in a car for an hour without a break 1 = I have a slight chance of dozing	2 = I have a moderate chance of dozingAs a passenger in a car for an hour without a break 2 = I have a moderate chance of dozing	3 = I have a high chance of dozingAs a passenger in a car for an hour without a break 3 = I have a high chance of dozing
Lying down to rest in the afternoon when circumstances permit	0 = I would never dozeLying down to rest in the afternoon when circumstances permit 0 = I would never doze	1 = I have a slight chance of dozingLying down to rest in the afternoon when circumstances permit 1 = I have a slight chance of dozing	2 = I have a moderate chance of dozingLying down to rest in the afternoon when circumstances permit 2 = I have a moderate chance of dozing	3 = I have a high chance of dozingLying down to rest in the afternoon when circumstances permit 3 = I have a high chance of dozing
Sitting and talking to someone	0 = I would never dozeSitting and talking to someone 0 = I would never doze	1 = I have a slight chance of dozingSitting and talking to someone 1 = I have a slight chance of dozing	2 = I have a moderate chance of dozingSitting and talking to someone 2 = I have a moderate chance of dozing	3 = I have a high chance of dozingSitting and talking to someone 3 = I have a high chance of dozing
Sitting quietly after lunch without alcohol	0 = I would never dozeSitting quietly after lunch without alcohol 0 = I would never doze	1 = I have a slight chance of dozingSitting quietly after lunch without alcohol 1 = I have a slight chance of dozing	2 = I have a moderate chance of dozingSitting quietly after lunch without alcohol 2 = I have a moderate chance of dozing	3 = I have a high chance of dozingSitting quietly after lunch without alcohol 3 = I have a high chance of dozing
In a car while stopped for a few minutes in traffic	0 = I would never dozeIn a car while stopped for a few minutes in traffic 0 = I would never doze	1 = I have a slight chance of dozingIn a car while stopped for a few minutes in traffic 1 = I have a slight chance of dozing	2 = I have a moderate chance of dozingIn a car while stopped for a few minutes in traffic 2 = I have a moderate chance of dozing	3 = I have a high chance of dozingIn a car while stopped for a few minutes in traffic 3 = I have a high chance of dozing

New Patient Forms

Patient Information

Responsible Party

Primary Insurance Information

Secondary Insurance Information

Referral Information

Payment / Cancellation Policies

Insurance Policy

Billing Policy

Women

Denture Patients

Everyone

Consent

Financial Agreement

I HAVE READ AND UNDERSTAND AND AGREE TO THE ABOVE POLICY

Epworth Sleepiness Scale

Acknowledgement of Receipt of Notice of Privacy Policies