New Patient Forms

New Patient Forms

So we can ensure that we can provide you with the best care possible, please fill out the following private and secure HIPAA compliant form to the best of your abilities.
Patient Information
Full Name*

PrefixFirst NameMiddle NameLast Name
Preferred Name
Date of Birth

MonthDayYear
Gender*
Date of Birth*

MonthDayYear
Date
SingleMarriedOther
Social Security
Occupation
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Type:*
Phone Number*

Area CodePhone Number
Type:
Phone Number

Area CodePhone Number
E-mail*
example@example.com
Welcome to our Practice
How did you hear about our practice?*
Who can we thank for referring you to our practice?
Primary Dental Benefit Information

You can leave this section blank if you have already provided us this information.
Subscriber's Name
Subscriber's Date of Birth

MonthDayYear
Date
Name of Dental Benefit Plan
Relationship of patient to subscriber
Member ID or SSN#
Group #
Employer Name
No Insurance
Upload a photo of your insurance card

Upload a File

Cancelof
Take a photo of your insurance card on your phone
Secondary Dental Benefit Information

You can leave this section blank if you have already provided us this information.
Subscriber's Name
Subscriber's Date of Birth

MonthDayYear
Date
Name of Dental Benefit Plan
Relationship of patient to subscriber
Member ID or SSN#
Group #
Employer Name
Upload a photo of your insurance card

Upload a File

Cancelof
Take a photo of your insurance card on your phone
In case of Emergency
Emergency Contact Name*
Phone Number

Area CodePhone Number
Physician's Name
Phone Number

Area CodePhone Number
YesNo
If yes, please give details
Pharmacy*
Address*
Your Medical History
Alzheimers/DementiaAnxietyArthiritisArtificial Heart ValveArtificial jointsAsthmaAtrial fibrillationLung Disorders/DiseaseCancerCerebral palsyChemotherapyChronic PainColitisCrohn's diseaseDepressionDiabetesDysrhythmiaEmphysemaEpilepsy/SeizuresEye ProblemsFatigueFibromyalgiaGastoparesisGERD/Acid RefluxGlaucomaHay FeverHeart (Surgery, Disease, Attacks)Heart DiseaseHeart MurmurHepatitisHerpesHIVHypercholesterolemia- High cholesterolHyperlipidemia- High fat in bloodHypertension-High Blood Pressure HBPHypothyroidism-underactive thyroidHyperthyroidism-overactive thyroidHypotension- Low Blood PressureJoint ReplacementKidney ProblemsLiver DiseaseMesotheliomaMigrainesMitral valve prolapseMultiple SclerosisNasal Obstruction/Deviated SeptumOsteoporosisPacemakerParkinson's diseasePsychiatric/Psychological CareRadiation TherapyRheumatoid autoimmune diseaseSexually Transmitted DiseaseSleep ApneaStrokeTrigeminal neuralgia painNO MEDICAL ISSUESOther
YesNo
If yes, please give details
YesNo
YesNo
YesNo
If yes, please give details
YesNo
If yes, how many weeks?
AcetaminophenAmoxicillin/PenicillinAspirinClindamycinCodeineErythromycinIbuprofenLatexLocal AnestheticMetalSulfaOther
YesNo
If yes, please give details
YesNo
If yes, please write down the name of the medication and reason for taking it. If you have a large list, upload a document or take a photo of your list on your phone below and submit it.
Upload a photo or document of your medication list

Upload a File

Cancelof
Take a photo of your medication list on your phone
Your Dental History
Reason for your dental visit*
Previous bad experience at the dentistJaw clicks or hurtGrind/clench teethOrthodontic (braces) treatment - Currently [Contact Ortho office to coordinate]Orthodontic (braces) treatment - PreviouslyUse a night guardPeriodontal (gum) treatment or deep cleaningBleeding gums when brushing teeth or flossingBad breathSensitive teeth to hot/coldOther issues
Is there any other concerns about your teeth? If yes, please give details.
YesNoUnsure
If yes, which procedures are you particularly interested in?
Previous Dental Office*
How long since your last dental appointment?*
YesNoUnsure
Yes - please see belowNo
If Yes, please contact your previous office and sign a Records Release form. Forward records to records@picachodental.com before your scheduled reservation to avoid additional charges.
Preferred Communication Method
TelephoneEmailText
Privacy & Confidential Information
YesNo
YesNo
Terms & Conditions
Consent for Treatment:
- I hereby authorize the dentist or designated staff to take radiographs, study models, photographs and other diagnotic aids deemed appropriate by the dentist to make a thorough diagnosis as mutually agree upon by me.
- Upon such diagnosis, I authorize the dentist to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide the appropriate care.
- I agree to be responsible for payment of all services rendered on my behalf and/or on behalf of my dependants. I understand that payment is due at anytime of service unless other arrangements have been made.
Payment for Treatment:

Payment is due at the time of service.

For your convenience, we accept the following payment methods: Cash, Visa, MasterCard, American Express, Discover, Cashier’s checks, CareCredit®, and SunBit.

Financial Policy:

Insurance benefits are determined by your employer, not your dentist. Your insurance policy is a contract between you and your insurance company. Insurance is not a guarantee of payment and your benefit may not match your individual treatment needs.

You are responsible for advising our office if you have a change in your insurance coverage prior to your appointment. As a courtesy, we are able to file insurance claims on your behalf for up to 2 insurance policies per patient. Every reasonable effort will be made to verify your insurance benefit and accurately estimate both your benefit and the portion of payment for which you will be responsible. Any deductible and/or estimated co-payment will be due at the time of service.

If we are unable to verify your insurance benefit, you will be expected to pay for the services rendered at the time of service.

If your insurance company has not paid your claim within 45 days, the remaining balance is your responsibility and is considered due and collectible at that time.

Cancellation Policy:

Appointments are reserved exclusively for you. We reserve the right to charge a fee for broken appointments – appointments that are missed, canceled or rescheduled without a 2 business days’ notice. A fee of $75 will be incurred for a broken appointment.

I understand the consent for treatment and policies as stated above.

By my electronic signature below, I agree to the terms and conditions.

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health and I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form. It is my responsibility to inform the dental office of any changes in medical status.
Signature*

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.
Relationship to Patient*
Name of signee if other than patient
**In Office Use** Dr. Initial
Should be Empty:

Patient Information

Welcome to our Practice

Primary Dental Benefit Information

Secondary Dental Benefit Information

In case of Emergency

Your Medical History

Your Dental History

If Yes, please contact your previous office and sign a Records Release form. Forward records to records@picachodental.com before your scheduled reservation to avoid additional charges.

Preferred Communication Method

Privacy & Confidential Information

Terms & Conditions

I understand the consent for treatment and policies as stated above.