WECare New Patient Paperwork | Secure Online Form

PATIENT REGISTRATION & HEALTH HISTORY
Full Name of Patient
Date

MonthDayYear
Date
Patient’s Date of Birth

MonthDayYear
Date
Gender
Is the patient a minor (under the age of 18)?

YesNo
Address (please include city, state and zip)
Email
example@example.com
Home Phone
Cell Phone
Work Number
Emergency Contact Info
IN CASE OF EMERGENCY, PLEASE CONTACT
Name of Emergency Contact
Relationship to Patient
Emergency Contact Number
Dental Insurance
Insurance Company
Subscriber ID
Subscriber’s Name
Relationship to Patient
Subscriber’s Date of Birth

MonthDayYear
Date
Subscriber’s Social Security #
Is the patient covered by additional insurance?

YesNo
Secondary Insurance Company
Subscriber ID
ASSIGNMENT AND RELEASE

I certify that I and/or my dependent(s) have insurance coverage with the above named Insurance Company(ies) and assign directly to Westford Endodontic Care all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

Westford Endodontic Care may use my healthcare information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.
Signature of Responsible Party

Clear
Date

MonthDayYear
Date
Printed Name
Relationship to Patient
Healthcare Information
Name of General Dentist
Reason for today’s visit
Physician’s Name
Physician Phone
Dental Health History
PLEASE CHECK THE BOX TO INDICATE IF YOU HAVE EXPERIENCED ANY OF THE FOLLOWING:

Bad breathFood collecting between teethOrthodontic treatmentBleeding gumsForeign objectsPain around earBlisters on lips or mouthGrinding or clenching teethPeriodontal treatmentBurning sensation on tongueGums swollen or tenderSensitivity to coldChew on one side of mouthJaw pain or tirednessSensitivity to heatChewing tobaccoLip or cheek bitingSensitivity to sweetsClicking or popping jawLoose teeth or broken fillingsSensitivity when bitingDry mouthMouth breathingSmoking / VapingFingernail bitingMouth pain during brushingSores or growths in your mouth
HOW OFTEN DO YOU FLOSS?
HOW OFTEN DO YOU BRUSH?
Health History
Do you need to take antibiotics prior to receiving dental care?

YesNoI don't know.
If yes, for what condition:
Name of antibiotic:
Dosage:
Have you ever used a bisphosphonate medication? (Fosamax, Actonel, Atelvia, Didronel, Boniva)

YesNo
Have you ever taken any of the group of drugs collectively referred to as “fen-phen?” These include combinations of lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)

YesNo
Have you ever been exposed to or tested positive for COVID-19 (Coronavirus)?

YesNoI don't know.
PLEASE CHECK THE BOXES TO INDICATE IF YOU HAVE EXPERIENCED ANY OF THE FOLLOWING CONDITIONS:
CARDIAC ISSUES

Angina PectorisArtificial Heart ValvesCongenital Heart LesionHeart Murmur/Mitral Valve ProlapseHeart Attack/Myocardial InfarctionHeart FailureHeart SurgeryHigh Blood PressureLow Blood PressurePacemaker/AICDRheumatic/Scarlet FeverStroke
CHRONIC CONDITIONS

Acid Reflux/HeartburnArthritis. Rheumatoid/OsteoArtificial Joints/ProsthesesCortisone TreatmentsDiabetesGlaucomaJaundiceKidney DiseaseLiver DiseaseSubstance Use DisorderThyroid Problems
NEUROLOGICAL/COGNITIVE

AnxietyDepressionDementiaEpilepsy/SeizuresFainting/Dizziness/VertigoHeadachesParalysis/WeaknessPsychiatric Care
INFECTIOUS CONDITIONS

AIDS/HIVHepatitisHerpes/Cold SoresSkin RashSwollen Neck/GlandsTuberculosisVenereal Disease
BLOOD DISORDERS

Bleeding AbnormalitiesHemophiliaSickle Cell AnemiaAnemia
CANCER-RELATED

ChemotherapyRadiation TherapyTumor or Unusual GrowthWeight Loss, Unexplained
RESPIRATORY ISSUES

CoughEmphysemaShortness of BreathSinus TroubleTuberculosis
PAIN CONDITIONS

Acute PainChronic Pain
FOR WOMEN

Taking Oral ContraceptionPregnantNursing
OTHER: Conditions not listed
Medications
Pharmacy Name
Phone Number
Pharmacy Address

Please list any medications you are currently taking (including herbal supplements) and the correlating condition:

	MEDICATION	CONDITION	DOSAGE

Allergies
PLEASE CHECK THE BOX TO INDICATE IF YOU HAVE AN ALLERGY TO ANY OF THE FOLLOWING:

Acetaminophen (Tylenol)NSAIDS (Ibuprofen, Advil, Naproxen, Naprosyn)CodeinePenicillinLocal AnestheticsSulfaLatexOther (please list below)
If you checked yes to any of the above, please describe the nature of your allergic reaction:
INFORMED CONSENT FOR GENERAL DENTAL PROCEDURES
You, the patient, have the right to accept or reject dental treatment recommended by your dentist. Prior to consenting to treatment, you should carefully consider the anticipated benefits and commonly known risks of the recommended procedure, alternative treatments, or the option of no treatment.

Do not consent to treatment unless and until you discuss potential benefits, risks, and complications with your dentist and all of your questions are answered. By consenting to the treatment, you are acknowledging your willingness to accept known risks and complications, no matter how slight the probability of occurrence.

It is very important that you provide your dentist with accurate information before, during, and after treatment. It is equally important that you follow your dentist’s advice and recommendations regarding medication, pre- and post- treatment instructions, referrals to other dentists or specialists, and return for scheduled appointments. If you fail to follow the advice of your dentist, you may increase the chances of a poor outcome.

Please read and initial each item below, then sign at the bottom of the form.

1. TREATMENT TO BE PROVIDED: I understand that during my course of treatment, the following care may be provided:
- Examinations
- Endodontic Therapy
PATIENT INITIALS*
2. DRUGS AND MEDICATIONS: I understand that antibiotics, analgesics, and other medications can cause allergic reactions causing redness and swelling of tissues; pain, itching, vomiting, and/or anaphylactic shock (a severe allergic reaction
PATIENT INITIALS*
3. CHANGES IN TREATMENT PLAN: I understand that it may be necessary to change or add procedures during treatment because of conditions found during the course of treatment that were not discovered during examination, the most common being root canal therapy following routine restorative procedures. I give my permission to the dentist to make any/all changes and additions as necessary.
PATIENT INITIALS*
4. INSURANCE: I give permission to Westford Endodontic Care to bill my dental insurance provider for the treatment provided, if applicable.
PATIENT INITIALS*
Date

MonthDayYear
Date
Signature of patient, parent, guardian or personal representative

Clear
Should be Empty:

PATIENT REGISTRATION & HEALTH HISTORY

Emergency Contact Info

Dental Insurance

Healthcare Information

Dental Health History

Health History

Medications

Allergies

INFORMED CONSENT FOR GENERAL DENTAL PROCEDURES