NEW PATIENT FORM

  • NEW PATIENT FORM

    CONTACT, HEALTH, & INSURANCE DETAILS

  • Patient Contact Information

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  • How did you hear about us?

  • Insurance Information

  • Do you have Dental Insurance?*
  • Can you upload a photo of your insurance card?
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  • Do you have secondary insurance?

  • Patient Medical History

  • Are you in good health?*
  • Do you have any serious health concerns?*
  • Are you presently under medical treatment?*
  • Do you have any allergies? Check all that apply:*
  • Abnormal Bleeding*
  • Heart Disease*
  • Angina, Chest Pain, or Pacemaker*
  • Rhuematic Heart Disease*
  • High Blood Pressure*
  • Joint or Valve Replacement*
  • Pregnant or Nursing*
  • Respiratory Problems or Difficulty Breathing*
  • Asthma or Tuberculosis*
  • Hepatitis (A or B)*
  • History of Cancer or Tumor*
  • Diabetes*
  • AIDS or HIV*
  • Marked Weight Change*
  • Are you currently taking any medications?*
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  • Have you ever taken any of the following medications? Check all that apply.*

  • Screening for Covid-19

  • Do you have a persistent cough?
  • Do you have shortness of breath?
  • Do you have chills and/or body aches?
  • Do you have temperature greater than 100.2°?
  • Do you have any loss of taste or smell?
  • Do you have any other health problems or issues?*
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  • PATIENT DENTAL INFORMATION

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  • Do you have Dental problems now?
  • Are you dissatisfied with the appearance of your teeth?
  • Do you have mouth pain?
  • Do you have broken teeth?
  • Do you have teeth that are sensitive to: (mark all that apply)

  • Have you ever had any of the following? (mark all that apply)
  • Have you notices any loosening or movement of your teeth?
  • Does food get caught between your teeth?
  • Are you concerned with bad breath?
  • Do you have pain and/or swelling in your gums?
  • Do your gums often bleed when you brush your teeth?
  • Do you ever get sores in your mouth?
  • Do you have sinus problems or infections?
  • Have you experience any of the following? (mark all that apply)

  • Do you smoke or chew tobacco?
  • Do you clench or grind your teeth while awake or asleep?
  • Do you bite your lips or cheeks regularly?
  • Do you hold foreign objects with your teeth? (pencils, pipe, pins, fingernails)
  • Do you mouth breathe while awake or asleep?
  • Do you suck on candy or mints regularly?
  • Do you have a history of gagging during dental treatment?

  • OFFICE POLICIES

    Please review these reminders

  • APPOINTMENTS: Please remember, the appointment time is reserved exclusively for you. This enables us to better serve each patient. If it becomes necessary, please reschedule or cancel appointments with our office at least two business days in advance. Our office assesses a charge for the time lost due to a late cancellation or missed appointment. As a courtesy, a voice message, text, or email reminder concerning appointment information will be left at the phone number/ email address you provide.

    FINANCES: Payment is due at the time services are rendered. We accept cash, checks, Visa, MasterCard, and American Express. A $20 monthly late fee and an interest charge (18% annual percentage rate) will be assessed on all past due accounts. A bank fee will be charged on all returned checks.

    DENTAL INSURANCE: As a courtesy to you, we will bill your insurance company for treatment rendered. However, it is the patient’s responsibility to know the current status of their insurance coverage and benefits. Our staff will estimate your co-payment based on the policy information provided by you. This amount will be due at the time of treatment. Actual coverage may vary from our estimate, as your insurance carrier ultimately determines participant eligibility and claim benefits. The financial responsibility for the work you receive in our office is strictly between you and Dr. Turner, regardless of insurance participation.

    • I understand and agree to the foregoing office policies and I hereby agree to accept responsibility for full payment of all treatment fees regardless of any insurance payment or participation.
    • I consent to any and all examination and treatment which may be deemed advisable, including the administration of local anesthetics and other medications.
    • I consent to have the dental office use my cell/mobile phone number to call or text me regarding treatment, appointments, my dental insurance, and my account. I understand I can withdraw my consent at any time.
    • In addition, I hereby acknowledge that I have been given the right to review a copy of this office’s Dental Materials Fact Sheet and the Notice of Privacy Practices as required by California State law.
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