New Patient Paperwork

Patient Acquaintance Form
Name:
Address:
City:
State:
Zip:
Home Phone:

Area CodePhone Number
Work Phone:

Area CodePhone Number
Cell:

Area CodePhone Number
E mail:
example@example.com
Birthdate:

MonthDayYear
Date
Marital Status

SingleMarried
Social Security #
Sex:

MaleFemale
Insurance Coverage:

YesNo
Name of Insured:
Date of Birth of Insured:

MonthDayYear
Date
Social Security of Insured:
Employer Name:
Referred By:
Medical History
Are you allergic to any drugs or medications? (Yes/No) If yes, please list

YesNo
List Drugs or Medications
Do you have artificial joints such as knee or hip replacements? If yes, please list with date:

YesNo
List Surgey Type
Surgey Date

MonthDayYear
Date
High blood pressure? (Yes/No) If yes, please list medication:

YesNo
List Medications
A heart ailment, including mitral valve prolapse or heart murmur? (Yes/No)

YesNo
Do you have a history of heart surgery? (Yes/No) If yes, please list:

YesNo
History of Heart Surgey:
Do you have Diabetes? Do you have Rheumatic fever? Do you have HIV or AIDS? If yes, please list medication:

DiabetesRheumatic feverHIV or AIDS
List Medication for Diabetes, Rheumatic fever, HIV or AIDS:
Do you have Hepatitis? (Yes/No) If yes, please list type:
Have you ever had any radiation treatment? Do you have epilepsy, convulsions, or seizures? Do you have any pain in or near your ears? Check all that apply.

Radiation Treatment?Epilepsy , Convulsions or Seizures?Pain in or Near your Ears?
Are you pregnant? (Yes/No) If yes, how many months?
Are there any other conditions we should be aware of?
Are you presently taking drugs or medications not listed above for any other medical condition? If so, please list, if not enter "None"*
List Medications
Dental History
Do you have or have you ever had any of the following: Click all that apply

Bleeding, sore gumsClenching/grinding?Clicking/popping jaw?
Do you have or have you ever had any of the following: Click all that apply

Sensitive teeth (hot or cold)?Teeth sensitive to sweets?Orthodontic Treatment for BracesDeep cleanings-Scaling/root planning
Dental Hygiene *
Is there anything about your teeth you would like to change?
Do you want whiter teeth?
In case of emergency,notify:
Phone Number

Area CodePhone Number
Unless prior arrangements have been made, payment is expected at time of service. In order to provide the best possible service, please notify us at least 24 hours in advance if you are not able to keep an appointment. Broken appointments will be subjected to a charge.

I certify that the above information is true and accurate to the best of my knowledge. I accept full financial responsibility for my account, including any fees which are assessed to my account to collect any outstanding balance.
Signature*

Clear
Date

MonthDayYear
Date
COVID-19 PANDEMIC - PATIENT DISCLOSURES
This patient disclosure form seeks information from you that we must consider before making treatment decisions in the circumstance of the COVID-19 virus.

A weak or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD, cancer treatment, radiation, chemotherapy, and any prior or current disease or medical condition), can put you at greater risk for contracting COVID- 19. Please disclose to us any condition that compromises your immune system and understand that we may ask you to consider rescheduling treatment after discussing any such conditions with us.

It is also important that you disclose to this office any indication of having been exposed to COVID-19, or whether you have experienced any signs or symptoms associated with the COVID-19 virus.
Do you have a fever or above normal temperature?*

YesNo
Have you experienced shortness of breath or had trouble breathing?*

YesNo
Have you recenly lost or had a reduction in you sense of smell?*

YesNo
Have you been in contact with someone who has tested positive for COVID-19?*

YesNo
Have you tested positive for COVID-19?*

YesNo
Have you been tested for COVID-19 and are awaiting results?*

YesNo
Have you traveled outside the United States by air or cruise ship in the past 14 days?*

YesNo
Name*

First NameLast Name
I fully understand and acknowledge the above information, risks and cautions regarding a compromised immune system and have disclosed to my provider any conditions in my health history which may result in a compromised immune system. By signing this document, acknowledge that the answers have provided above are true and accurate
Signature*

Clear
Date

MonthDayYear
Date
Compassionate Family Dentistry
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.

YesNo
Please print name
Signature

Clear
Date

MonthDayYear
Date
Authorization to release specific protected health information

*Per your request we are allowed to fax dental excuses to your school or business*
Please print name
Signature

Clear
Date

MonthDayYear
Date
For office use only

We attempted to obtain acknowledgement of receipt of our notice of privacy practices, but acknowledgement can not be obtained because
Individual refused to signcommunications barriers prohibited obtaining acknowledgementAn emergency situation prevented us from obtaining acknowledgementOther (please specify)
Should be Empty:

Patient Acquaintance Form

Medical History

Dental History

COVID-19 PANDEMIC - PATIENT DISCLOSURES