• New Patient Form

    Welcome! We want to help you live a longer, healthier life to be with those you love! So we may provide you the best possible care, please fill out these confidential forms as thoroughly as possible.

  • Patient Information

  • Date*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • What is the best way to reach you?*

  • Employer

    This information helps us file your insurance correctly.

  • Referral Source

    Whom may we thank for referring you? ALL REFERRALS EARN $100 Dental Dollars FOR YOU & YOUR FRIEND!
  • Not referred - What made you call?

  • Guarantor: Person Financially Responsible

  • Insurance

    Your oral health is connected to your total health, so we may get coverage through your medical insurance for some procedures.

  • Primary Insurance

  • Is insured a patient?
  • Do you have medical insurance?*
  • Is insured a patient?

  • Primary Care Provider

    We partner with your Physician to help you live a longer, healthier life!
  • Format: (000) 000-0000.

  • Emergency Contact

  • Format: (000) 000-0000.

  • Closest Relative

    (Not Living with You)
  • Format: (000) 000-0000.

  • Dental History

  • Date of Last Dental Visit
     - -
  • Last Cleaning?
     - -
  • Last Full Mouth X-Rays?
     - -
  • Format: (000) 000-0000.
  • What other dental aids do you use?
  • Do you have any dental problems now?*

  • Are Any of Your Teeth Sensitive To

  • Hot or Cold?*
  • Sweets?*
  • Biting or Chewing?*
  • Have you noticed any mouth odors or bad tastes?*
  • Do you frequently get cold sores, blisters, or any other oral lesions?*
  • Do your gums bleed or hurt?*
  • Did your parents experience gum disease/tooth loss?*
  • Have you noticed loose teeth / change in your bite?*
  • Does food get caught in between your teeth?*

  • Have you Ever Had

  • Orthodontic Treatment?*
  • Oral Surgery?*
  • Periodontal Treatment?*
  • Your teeth ground or bite adjusted?*
  • A bite plate or mouth guard?*
  • A serious injury to the mouth or head?*

  • Do you

  • Clench or grind your teeth while awake or asleep?*
  • Bite your lips or cheeks regularly?*
  • Hold foreign objects with your teeth? (pencils, pipe, pins, nails, fingernails)*
  • Mouth breathe while awake or asleep?*
  • Have tired jaws, especially in the morning?*
  • Snore or have any other sleeping disorders?*
  • Do you have sleep apnea or a c-pap machine?*
  • Smoke/chew tobacco or use other tobacco products?*

  • Have You Experienced

  • Clicking or popping of the jaw pain? (Joint, Ear, Side of Face)*
  • Difficulty in opening or closing the mouth?*
  • Difficulty in chewing on either side of the mouth?*
  • Headaches, neck aches, or shoulder aches?*
  • Sore muscles (neck, shoulders)?*

  • Botox

  • Do you have any interest in Botox for TMD or Fine Lines?*

  • Your Smile

  • Are you satisfied with your teeth's appearance?*
  • Would you like to keep all your teeth all your life?*

  • Your Dental Experiences

  • Do you feel nervous about having dental treatment?*
  • If so, what is your biggest concern?*
  • Have you ever had an upsetting dental experience?*
  • Is there anything else about having dental treatment that you would like us to know?*

  • Medical History

  • Have you been under the care of a medical doctor during the past two years?*
  • Have you taken any medication or drugs in the last two years?*
  • Are you taking any medication or drugs currently, including regular doses of aspirin or over-the-counter herbal medicines?*
  • Have you ever taken any prescription drugs for weight loss, including Fen-Phen (fenfluramine-phentermine), Pondimen (fenfluramine), and Redux (dexfenfluramine)?*
  • If yes, did you have a medical exam for heart issues?*
  • Are you aware of having any allergic or adverse reaction to any medication or substance?*
  • Have you been a patient in the hospital in the last 5 years?*

  • Indicate which of the following you have had, or have at present. Select “Yes” or “No” for each item.

  • Heart (Surgery Disease Attack)*
  • Chest Pain*
  • Congenital Heart Disease*
  • Heart Murmur*
  • High Blood Pressure*
  • Mitral Valve Prolapse*
  • Artificial Heart Valve*
  • Heart Pacemaker*
  • Rheumatic Fever*
  • Arthritis/Rheumatism*
  • Cortisone Medicine*
  • Swollen Ankles*
  • Stroke*
  • Diet (Special/Restricted)*
  • Artificial Joints*
  • Kidney Trouble*
  • Ulcers*
  • Diabetes*
  • Thyroid Problems*
  • Glaucoma*
  • Contact Lenses*
  • Emphysema*
  • Chronic Cough*
  • Tuberculosis*
  • Asthma*
  • Hay Fever*
  • Latex Sensitivity*
  • Allergies or Hives*
  • Sinus Trouble*
  • Radiation Therapy*
  • Chemotherapy*
  • Tumors*
  • Hepatitis A B C*
  • Venereal Disease*
  • AIDS*
  • HIV Positive*
  • Cold Sores/Fever Blisters*
  • Blood Transfusions*
  • Hemophilia*
  • Sickle Cell Disease*
  • Bruise Easily*
  • Liver Disease*
  • Yellow Jaundice*
  • Neurological Disorders*
  • Epilepsy or Seizure*
  • Fainting or Dizzy Spells*
  • Nervous/Anxious*
  • Psychiatric/Psychosocial Care*
  • Do you use more than two pillows to sleep?*
  • Have you lost or gained more than 10 pounds in the past year?*
  • Do you have or had any disease, condition, or problem not listed?*

  • Women Only

  • Are you pregnant or think you may be pregnant?*
  • Are you nursing?*
  • Do you use birth control medicines?*

  • I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the dentist of any changes in my health or medication.

  • Date*
     - -

  • Patient authorization, agreements, & acknowledgements

  • Here’s to a Healthy Start! Please review how we handle the business aspect of our practice. Our #1 goal is to help you live a longer, healthier life, so you can be around longer with those you love. All this information helps us get on the same page now, so we can help you do that!

  • Making Appointments: I agree that any appointment I make with Dr. Hepler’s office is confirmed upon scheduling. I may receive courtesy reminders where I may click a “confirm” button, but if I make an appointment, they are expecting me to show up. Please check any that apply. How would you like your courtesy appointment reminders?

  • *

  • Cancellation Fees: In order to better serve you, we do not double book our patients. We require 48 hour notice if you are unable to make your appointment to avoid a cancellation fee of $50 for hygiene appointments & $50 per 30 min for Doctor appointments. As small business owners, this still causes us financial hardship as these fees don’t make up for the cost of broken appointments, but we hope they are a deterrent. We value and respect your time and expect the same of you. Broken appointment time drives up the cost of dentistry for everyone, so please help us keep it affordable by keeping reserved appointments.

    Consent for Treatment: I hereby authorize Dr. Hepler or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of my dental needs. Upon such diagnosis, I authorize Dr. Hepler to perform all prescribed 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. I give consent to D r. Hepler or designated staff’s use and disclosure of any oral, written, or electronic health records that are individually identifiable as mine for the purpose of carrying out my treatment, payment, and health care operations. I understand that only the minimum amount of inf ormation necessary to provide quality care will be used or disclosed, and that a notice fully outlining the protection of my personal health information is available.

    Insurance Information: As a courtesy to our patients, our office will assist you in obtaining maximum benefits from your insurance. However, there are many misconceptions about dental insurance. Dental insurance pays based on the premium paid by you or your employer. Higher premium plans pay more of the fees for your dental care and have fewer exclusions. Dental insurance helps defray the costs of dental care, but it is not intended to cover it completely. Insurance requires patients to pay a portion of the fee that insurance does not cover. This is your Estimated Patient Portion

    Dental insurance policies restrict payment for some services, use restricted fee schedules, and exclude some procedures based on prior conditions or length of time on the plan. Restrictions can be based on the premium paid for insurance. While our business team will do our very best to research your insurance, in the end, this is a contract between you, your insurance carrier, and your employer. We love helping our patients with insurance as a courtesy, but you are ultimately responsible for understanding your plan, it’s conditions, limitations, restrictions, and exclusions. Additionally, you are financially responsible for any balance your insurance does not cover.

    • Secondary Insurance: We are happy to file your primary and secondary dental insurance on your behalf as a courtesy and service to you. We require you pay anything that your primary insurance does not cover. As a courtesy to you, we will submit the necessary forms to your secondary insurance carrier, and the secondary insurance carrier will reimburse you directly.
    • Medical Insurance: We are excited about the opportunities to serve our patients by learning about the latest in dental-medical cross-coding because, the current science shows us the importance of oral health to the systemic wellness of the whole body! We are diligently learning about how to file dental needs under the appropriate medical codes to get coverage and benefits for our wonderful patients. We do require that you pay for all your services based on the Estimated Patient Portion that your primary dental insurance carrier will provide. We will submit the appropriate medical claims as allowed, and allow your medical insurance to reimburse you directly.

  • Billing & Agreement to Pay: We estimate your portion on the date of service based on the insurance information we have at the time. It is the patient’s responsibility to keep our office updated with the most current insurance information. Our estimates are never a guarantee of how the insurance company will pay. Should the insurance company delay or deny payment for any reason, the balance will be your responsibility within 45 days.

    I understand that all responsibility for payment for dental services provided in this office for myself or my dependents is mine. The undersigned accepts the fee charges as a lawful debt and promises to pay said fee including the costs of collection, attorney fees, and court costs if necessary. I agree to pay my deductible and any portion of the dental fee not covered by my dental insurance plan at the time of service. In the event payment is not received by agreed upon dates, I understand that a 1.5 % late charge (18% APR) may be added to my account. If required, I also understand a check of my credit history may be made.

    Privacy Practices Acknowledgement: I have received the Notice of Privacy Practices and I have been provided an opportunity to review it.

    Confidentiality and Use and Disclosure of Information: You understand that information obtained in this form will be treated as privileged and confidential and will not be released or revealed to any third party (other than for treatment, payment, or health care operations purposes) without your authorization, as described below. Dr. Hepler is committed to continuing education. Your photos, dental models and pertinent dental and medical histories may be shared with other health professionals and patients for the purpose of education, marketing, review, and learning. Your personal information will be protected. Your signature below indicates your authorization for the dentist and the dentist’s staff to use your photos and dental records. This would authorize the publication and computer illustration of your photos for educational and marketing purposes, and you will waive all claims against any party based on the usage of the images, including, but not limited to, claims that the use of the images defames you or constitutes an infringement of your rights to privacy, or any other right you may enjoy.

    Signature on File: I authorize the release of information to all insurance companies and permit this copy of my signature to be kept on file for processing dental insurance claims for me and my dependents. I also understand this dental office has no contract or connection with my dental insurance company. I authorize payment to go directly to my dentist. I will notify this office if I have a change in my dental coverage.

  • I have read, understand, and agree to these authorizations, agreements, and acknowledgements.

  • Date*
     - -
  • Should be Empty: