• Patient Information

  • Today's Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Sex
  • Marital Status

  • Date of Birth
     / /
    2 digit month, 2 digit day, 4 digit year
  •  -
  •  -

  • Health Information

  • Date of last dental visit
     / /
    2 digit month, 2 digit day, 4 digit year
  • Have you ever had any of the following?
    Rows

  • Health History

    Continued
  • Have you ever had any complications following dental treatment?
  • Have you been admitted to a hospital or needed emergency care during the past two years?
  • Are you now under the care of a physician?
  •  -
  • Do you have any health problems that need further clarification?
  • Are you taking any medications?

  • Cosmetic Information

  • Referral Information

  • Whom may we thank for referring you to our practice

  • Spouse or Responsible Party Information

  • The following is for:
  • Sex
  • Marital Status

  • Employment Information

  • The following is for:

  • Insurance Information

  • Insured Birth Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Is the insured a patient?
  • Patient's relationship to insured

  •  -

  • Consent for Services

  • To the best of my knowledge, all of the preceding I hereby authorize Dr. Dooley and/or staff to take x-rays, models, photographs and other diagnostic aids deemed appropriate by Dr. Dooley to make a thorough diagnosis of my/my child’s dental needs. Upon such diagnosis, I authorize Dr. Dooley to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care. I agree to the use of anesthetics, sedatives and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.

    As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon payment from the patients for the costs incurred in their care, and financial responsibility on the part of each patient must be determined before treatment. All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in full at the time services are performed.

    As a courtesy this office will prepare the patient’s insurance forms and accept direct payment from your insurance company. All insurance benefit figures are estimates only. Patients with dental insurance understand that all dental service fees are the responsibility of the patient and the patient is personally responsible for payment of all dental services.

    I understand that any fee estimate provided by this office for my dental care will be honored for a period of ninety (90) days from the date of the patient examination.

    I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form.

    Our practice is dedicated to exceptional care and service. Because many of our patients want specific appointment times during the day, we have adopted guidelines to allow our patients to pre-reserve certain appointments. In order to serve everyone efficiently; we require 48 hour notice for any appointment changes. A $35.00 charge will be assessed for broken and missed appointments without advance notice. Exceptions will be made for emergencies. Thank you for your cooperation and for allowing us to serve all of our patients.

  • Acknowledgement of Receipt of Notice of Privacy Practices

    * You May Refuse to Sign This Acknowledgement

  • I, * , have received a copy of this office's Notice of Privacy Practices.

  • Date
     / /
    2 digit month, 2 digit day, 4 digit year

  • For Office Use Only

    ******************

  • We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

    _____ Individual refused to sign

    _____ Communications barriers prohibited obtaining the acknowledgement 

    _____ An emergency situation prevented us from obtaining acknowledgement

    _____ Other (Please Specify)

     

  • Should be Empty: