New Patient Form

Todays Date*

MonthDayYear
Date
Whom may we thank for referring you to us, or how did you hear of us. *
Patient Information
Patient Name*
Date of Birth*
Social Security Number
Address*
City/State/Zipcode*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
If patient is a minor give parent or guardian's name
Responsible Party/Partner/Spouse's Name (type Self if no additional Responsible Party)
Insurance Information
Do you have insurance?*
Policy Holders Name

First NameLast Name
Policy Holders Birthdate
Policy Holders Social Security
Dental Insurance Company
Subscriber/Member ID number
Group Number
Insurance Company Address

Street Address Line 2

Street Address Line 2

CityState / Province

Postal / Zip Code
City
Insurance Company Phone
Policy Holder's Employer
Do you have dual coverage?
If Yes, Policy Holder's Name
Policy Holder's Birthdate

MonthDayYear
Date
Subscriber/Member ID number
Group Number
Insurance Company Address

Street Address Line 2

Street Address Line 2

CityState / Province

Postal / Zip Code
City
Insurance Company Phone

Area CodePhone Number
Emergency Contact
Name of nearest relative not living with you*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Relationship*
Dental History
Do you have a present complaint or concern that brought you into our office*
Last dental exam and xrays? estimate of date/year is okay*

MonthDayYear
Date
Last dental cleaning? estimate of date/year is okay*

MonthDayYear
Date
Previous Dentist Name/Office Name*
Previous Dentist Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

Please answer Yes or No to the following *

Rows	Yes	No
1. Are you fearful of dental treatment?
2. Have you had an unfavorable dental experience?
3. Have you ever had a complication from past dental treatment?
4. Have you every had trouble getting numb or had reactions to local anesthetic?
5. Did you ever have braces, orthodontic treatment, or had your bite adjusted?
6. Have you had any teeth removed, missing teeth that never developed or lost teeth due to injury or facial trauma?
7. Do your gums bleed sometimes or are they ever painful when brushing or flossing?
8. Have you ever been treated for gum disease or been told you have lost bone around your teeth?
9. Have you ever noticed an unpleasant taste or order in your mouth?
10. Is there anyone with a history or periodontal disease in your family?
11. Have you experienced gum recession, or can you see more of the roots of your teeth?
12. Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating
13. Have you experienced a burning or painful sensation in your mouth not related to your teeth?
14. Have you had any cavities within the past 3 years?
15. Does the amount of saliva in your mouth seem too little or do you have a difficulty swallowing any food?
16. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?
17. Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth?
18. Do you have grooves or notches on your teeth near the gumline?
19. Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?
20. Do you frequently get food caught between any teeth?
21. Do you have problems in your jaw joint?
22. Do you feel like your lower jaw is being pushed back when you try to bite your back teeth together?
23. Do you avoid or have difficulty chewing gum, carrots or other hard dry foods?
24. In the past 5 years, have your teeth changed (become shorter, thinner, or worn) or has our bite changes?
25. Are your teeth developing spaces or becoming loose?
26. Are your teeth becoming more crooked, crowed or overlapped?
27. Do you have trouble finding your bite, or shift your jaw to make your teeth fit together?
28. Do you place your tongue between your teeth or close your teeth against your tongue?
29. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?
30. Do you clench or grind your teeth?
31. Do you wear or have you ever worn a bite appliance?
32. is there anything about the appearance of your mouth that you would like to change?
33. Have you ever whitened (bleached) your teeth?
34. Have you felt uncomfortable or self conscious about the appearance of your teeth?
35. Have you been disappointed with the appearance of previous dental work?

Any additional dental concerns? Please list below or write N/A

Patient Financial Resource
Below is a resource for you to better understand how we utilize insurance benefits, the payment options we offer and responsible party information. Please ask if you have any questions about the information below.

Participating Insurance Companies—We participate with certain insurance companies and accept their payment as payment-in-full, excluding any copayments or deductibles indicated in the contract you have with your insurance company. We will do all we can to maximize your insurance benefits in order to keep your out-of-pocket costs as minimal as possible. We advise all or our patients to read through their insurance contract so they can have the knowledge and understanding of the plan prior to treatment.

Non-Participating Insurance Companies - We accept most insurance plans even though we are not considered to be a participating provider. This means that you will be responsible for your copayments, deductibles and any difference between our fees and the fees your insurance company chooses to accept. We will treat your insurance the same as we treat an insurance plan we participate with, meaning, we will do all we can to maximize your insurance benefits in order to keep your out-of-pocket costs as minimal as possible.

No Insurance Coverage-We offer payment plans designed to fit your personal needs. We also accept Cash, Check, Visa, Mastercard, Discover, American Express and Care Credit. If you are without insurance, we do collect payment at the time of service. If a payment plan is needed, we will work with you to find the best option that fits into your budget.

Regarding Multiple Dental Plans-Secondary insurances are a great asset! We will submit claims to both your primary and secondary.

By signing below, I understand that I am responsible for all fees for treatment regardless of insurance coverage.
Signature*

Clear
Date*

MonthDayYear
Date

Appointment Policies
To help us provide the best care to all our patients, we ask that you please respect our appointment and cancellation policies. When an appointment is scheduled, that time is reserved exclusively for you.

Appointment Confirmation Policy

Patients will receive a confirmation request (via phone call, text, or email) prior to their scheduled appointment. If a confirmation is not received by 5pm the day prior to appointment, the appointment will be cancelled and considered a missed appointment. It is the patient’s responsibility to ensure their appointment is confirmed.

Cancellation Policy

We require at least 48-hour notice if you need to cancel or reschedule an appointment. This allows us to offer that time to another patient in need of care.

Missed Appointment / No-Show Policy

A "no-show" is when a patient misses an appointment without calling to cancel. After 1 missed appointments without proper notice, we may require a non-refundable deposit to schedule future appointments or may discontinue services at our discretion.

Late Arrival Policy

If you arrive more than 15 minutes late for your scheduled appointment, we may not be able to accommodate you. It will be considered a missed appointment and may be subject to the same fees.

Fees

Missed/Late Appointment Fee: $50
Late Cancellation Fee: $50 if cancelled with less than 48-hour notice

Fees are not covered by insurance and will be billed directly to the patient.

Acknowledgment & Agreement

I have read and understand the Cancellation, No-Show, and Late Arrival policies of Harmony Dental. I agree to abide by these terms and understand that I may be charged a fee for failing to give proper notice or for missing my appointment.
Signature*

Clear
Date*

MonthDayYear
Date

Acknowledgment of Receipt of Statement of Privacy Practices
I acknowledge that I have received a copy of the Statement of Privacy Practices for the offices of Harmony Dental types of uses and disclosures of my protected health information that might occur in my treatment, payment or services, or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility.

Harmony Dental reserves the right to change the privacy practices currently described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed or otherwise transmitted to me.
ADDITIONAL DISCLOSURE AUTHORIZATION
In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my Protected Healthcare Information to the person(s) identified below. (I understand that the default answer is NO". Without indicating "YES" in answer to the each individual question, personal protected (PHI) cannot be shared with anyone unless otherwise allowed by HIPAA rules.)
Spouse only
Any member of my immediate family: (Spouse, Children, Children's Spouses)
Any member of my extended family: (Parents, Grandchildren)
List below any additional person(s) (Girlfriend, Boyfriend, Primary Doctor, other)
First and Last Name*
Patient's personal representative if not self
Relationship to Patient
Phone Number: *
I authorize the release of a full report of examination finding, diagnosis, treatment program etc., to any referring or treating dentist or physician. I additionally authorize the release of any medical information to insurance companies or for legal documentation. I understand I am responsible for all fees for treatment regardless of insurance coverage.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Rows	Yes	No
1. History of infective endocarditis
2. Heart problems, or cardiac stent within the last six months
3. Artificial heart valve, repaired heart defect (PFO)
4. Pacemaker or implantable defibrillator
5. Orthopedic or soft tissue implant (e.g joint replacement, breast implant)
6. Heart murmur, rheumatic or scarlet fever
7. High or low blood pressure
8. A stroke (taking blood thinners)
9. Anemia or other blood disorder
10. Prolonged bleeding due to a light cut (or INR>3.5)
11. Pneumonia, emphysema, shortness of breath, sarcoidosis
12. Chronic ear infections, tuberculosis, measles, chicken pox
13. Breathing problems (e.g. sleep apnea, stuffy nose, sinus congestion)
14. Sleep problems (e.g. sleep apnea, snoring, insomnia, restless sleep, bedwetting?
15. Kidney Disease
16. Liver disease or jaundice
17. Vertigo
18. Thyroid, parathyroid disease, or calcium deficiency
19. Hormone deficiency or imbalance (e.g. poly cystic ovarian syndrome)
20. High Cholesterol or taking statin drugs
21. Diabetes
22. Stomach or duodenal ulcer
23. Digestive or eating disorders (e.g. celiac disease, gastric reflux, bulimia, anorexia)
24. Osteoporosis/osteopenia or every taken anti-resorptive medication (e.g. bisphosphonates)
25. Arthritis or gout
26. Autoimmune disease
27. Glaucoma
28. Head or neck injuries
29. Epilepsy, convulsions (seizures)
30. Neurologic Disorders (ADD, ADHD, prion disease)
31. Viral Infections and cold sores
32. Any lump or swelling in the mouth
33. Hives, skin rash, hay fever
34. STI/STD/HPV
35. Hepatitis
36. HIV/AIDS
37. Tumor, abnormal growth
38. Radiation Therapy
39. Chemotherapy, immunosuppressive medication
40. Emotional difficulties
41. Psychiatric treatment or antidepressant medication
42. Alcohol/recreational drug use

Rows	YES	NO
43. presently being treated for any other illness
44. aware of a change in your health in the last 24 hours (e.g., fever, chills, new cough, or diarrhea)
45. taking medication for weight management
46. taking dietary supplements
47. often exhausted or fatigued
48. a smoker, smoked previously or other (smokeless tabacco, vaping, e-cigarettes, and cannabis)
49. considered a touchy/sensitive person
50. taking birth control pills
51. currently pregnant
52. diagnosed with a prostate disorder

Patient Information

Insurance Information

Emergency Contact

Dental History

Preferred Pharmacy

Medical History

Medication List

Patient Financial Resource

Appointment Policies

Acknowledgment of Receipt of Statement of Privacy Practices

ADDITIONAL DISCLOSURE AUTHORIZATION