Welcome To Our Office!

Name *

First Name Middle Name Last Name

Gender *

Male Female

I am *

Minor Single Married Divorced Widowed Separated

Birth Date *

Month Day Year

Social Security Number *

This will help verify insurance benefits.

Address *

Street Address

Apt

City State

Zip Code

Mobile *

Area Code Phone Number

Work

Area Code Phone Number

Email *

example@example.com

Emergency Contact: *

Name

Phone Number *

Area Code Phone Number

Relationship

Reason for visit

What brings you to the office today?

*

Are you currently taking any blood thinners? *

Yes No

When was your last dental exam?

Date

When were your last dental x-rays taken?

Date

How often do you brush?

# times/day

How often do you floss?

# times/day

Do you grind your teeth?

Yes No I don't know

Have you ever had orthodontic (braces) treatment?

Yes No

Have you ever had periodontal (gum) treatments?

Yes No

Do you have any of the following? *

Have you ever had any of the following? *

Have you ever smoked?

Yes No

Do you smoke now?

Yes No

Do you use recreational drugs?

Yes No

How much alcohol do you drink per week?

# drinks/week

How much caffeine do you drink per day?

# drinks/day

Are you pregnant?

Yes No

Are you breastfeeding?

Yes No

Employer: *

Insurance Company *

Member ID: *

Group Number

OPTIONAL: Upload Dental Insurance Card

Browse Files

Digital Insurance Card

Please provide us with your preferred pharmacy. If we need to prescribe you a medication, we will submit this electronically.

Name of Pharmacy

Street Address

City State / Province

Postal / Zip Code

Please read our following office policy and financial agreement. If there are any questions or concerns, please feel free to contact us.

This agreement is to inform you of your financial obligation to our practice. Please understand that payment of your bill is considered a part of your treatment. We are committed to providing you with the most comprehensive dental care using only the highest quality materials and technology available in the market today. We are also committed to providing you with up-to-date information and educational tools so that you may fully participate in maintaining optimum oral health.

All charges you incur are your responsibility regardless of any insurance coverage or benefit plan that may assist you in completing your dental treatment.

Additionally, our practice will charge you a fee of $75 for appointments that you do not keep and for appointments that you do not cancel with 24-hour notice. Your credit card will automatically be charged.

We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your insurance company. As a courtesy to you we will complete your insurance claims and submit to your insurance for payment. In order for our practice to seek reimbursement from your insurance company, we ask that you please provide us with all insurance information needed.

GENERAL CONSENT TO DIAGNOSE AND TREAT: The undersigned hereby authorizes Midtown Dental Group to take radiographs, study models, photographs, or any other diagnostic aids deemed appropriate to make a thorough diagnosis of the undersigned patient’s dental condition and needs. I authorize Midtown Dental Group to perform any and all forms of treatment, medication, and therapy that may be necessary and further consent that Midtown Dental Group choose and employ such assistance as deemed necessary. I understand that the use of local anesthetics agents embodies certain risk and consent to their use as deemed appropriate by Midtown Dental Group. To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect or incomplete information can be dangerous to my/ the patient’s health. It is my responsibility to inform the dental office of any change in medical health or status.

FINANCIAL CONSENT: I understand that responsibility for payment of services provided in this office for myself and my dependent(s) is mine, due and payable at the time services are rendered. I understand that I am responsible for any portion of fees for services rendered not covered by my dental or medical insurance (if any). I acknowledge that I am responsible for all fees necessary to collect my account. I authorize Midtown Dental Group and his staff to verify insurance coverage, if any, to submit claims and provide my insurance company with information required for a claim, to assign benefits payable to him, and to handle any necessary claim appeal(s) on my behalf.

New Patient Forms

Medical History

Allergies

Dental History

Past Medical History

Lifestyle Factors

Women Only

Insurance Information

Financial Agreement