Slone Dental New Patient Form

Slone Dental New Patient Form
Name*

PrefixFirst NameMiddle InitialLast Name
Preferred Name
Gender*

MaleFemale
Family Status*

MarriedSingleChildOther
Social Security Number*
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Preferred Contact Method:*

CallText
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Other Number
Emergency Contact

First NameLast Name
Emergency Phone
Please enter a valid phone number.
Best Time to Call
Name of person, insurance company or other source referring you to our practice:*
Here at Slone Dental we provide a very thorough, comprehensive exams. In order for us to provide you with the best possible experience, please choose from one of the following options:
Do you prefer to receive all the details about your oral health and treatment, or do you prefer to receive a summary?*

DetailsSummary
Preferred Pharmacy*
Preferred Billing Method*

Text (E-statements)Mailed Statements
Primary Insurance Information

(Please enter the information for the primary policyholder for your insurance plan below) Type "0" if it does not apply.
ID #*
Group #*
Date of Birth*

MonthDayYear
Date
Policy Holder's Name*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient's relationship to insured:*

SelfSpouseChildOther
Insurance Plan Name
Employer Name
Insurance Claims Address (Found on insurance card)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Provider 1-800 or 855 number on back of insurance card: (type 0 if not applicable)*
Please enter a valid phone number.
Policyholder's Social Security number: (type 0 if not applicable)*
Front of Insurance Card

Cancelof
Back of Insurance Card

Cancelof
Driver's License

Cancelof
* Please inform our front desk if you have a Secondary Insurance
Health History / Medical Alerts:
Select all medical alerts that applies to you:

Allergy - AspirinAllergy - KeflexAllergy - PenicillinAmelogenesisImperfecArtificial JointsBlood DiseaseBreathing ProblemsCold SoresDizzinessFever BlistersHeart DiseaseHigh Blood PressureLupusNervous DisordersPregnancyRadiation TreatmentStomach/IntestinalTuberculosisVenereal DiseaseAllergy - AugmentinAllergy - LatexAllergy - SeasonalAnemiaAspirin DailyBlood ThinnersBruise EasilyDiabetes Type IIEpilepsy/SeizuresGlaucomaHeart MurmurHIV/AIDSMental DisordersNo EpinephrinePre-MedicateRheumatic FeverStrokeTumors/GrowthsAllergy - CephadynAllergy - OmicefAllergy - SulfaArthritis/GoutAsthmaBlood TransfusionCancerDiabetes (Insulin)Excessive BleedingHead InjuriesHeart PacemakerKidney DiseaseMultiple sclerosisOCDPsychiatric TxRheumatismSwelling of LimbsUlcerative ColitisAllergy - CodeineAllergy - OtherAllergy: NSAIDSArtif. Heart ValveBisphosphonatesBreast FeedingChemotherapyDialysisFaintingHeart DefectHepatitisLiver DiseaseMVPPulm lung diseaseSinus ProblemsThyroid DiseaseUlcersOther
Have you reviewed and checked all applicable medical alerts?*

YesNo
If you have checked any of the medical alerts please explain:
Medication List:
Dental History
Have you ever taken bisphosphonates (Zometa, Aredia, Bonefos, Fosomax, Boniva, Actonel, Didronel, etc)?*

YesNo
How often do you floss?*

DailyWeeklyMonthlyNever
Have you ever received fluoride treatment with you past cleanings?*

YesNo
What dental aids do you use?

Electric toothbrushWaterpikFloss picks
Please rate your homecare and dental hygiene on a scale of 1-10, with 10 being the best:
Do you have any current dental problems?*

YesNo
When was your last dental cleaning?

MonthDayYear
Date
What is the name of your previous dentist?
PLEASE CHECK ALL THAT APPLY
Are your teeth sensitive to any of the following?

Hot or ColdSweetsBiting or Chewing
Do you experience any of the following?

Cold sores, fever blisters or any other lesionsOne or more parent has history of gum disease or tooth lossFood is easily trapped in between teethBite lips or cheeks regularlyMouth breathe while awake or asleepSnore/Sleep Apnea or any other sleep disordersDrink soda or energy drinksDifficulty opening or closing mouthPain in joint, ear or side of faceBleeding or painful gumsLoose teeth/change in biteClench or grind your teeth while awake or asleepHold foreign objects with your teeth (pencils, pipe, pins, nails,fingernails)Tired jaws, especially in the morningSmoke/chew tobacco, dip or use E-cigaretteClicking or popping of the jawSore muscles in neck or shouldersHeadaches or migraines
Have you ever had...

Orthodontic treatmentOral SurgeryPeriodontal treatmentBite plate, mouth guard or snore guardEndodontic treatmentSerious injury to the mouth or headNone of the above
Are you satisfied with your teeth's appearance?*

YesNo
Do you feel nervous about having dental treatment?*

YesNo
Have you ever had an unpleasant dental experience?*

YesNo
Have you ever been told to take pre-medication prior to dental treatment?*

YesNo
Is there anything else about having dental treatment that you would like us to know?*

YesNo
To the best of my knowledge, all of my answers are correct and complete. If there are ever any changes in my health or medications, I will inform the dentist and staff. *
Slone Dental Office Policies
CANCELLATION AND BROKEN APPOINTMENT POLICY

A reserved appointment time in any dental office is limited and valuable. It is extremely important that all patients honor their reserved dental appointments. Failure to do so deprives our other patients from receiving their dental care in a timely fashion.

Those who fail to keep their scheduled appointments should not penalize the Dentist, our staff, and mainly our other patients. Our dental policy stipulates that failure to give sufficient notice to keep a scheduled appointment will result in a fee being charged. That charge is in accordance with our dental office's broken appointment policy for all of our patients. The patient is responsible for the payment of the charge.

Cancellation, rescheduling, or failure to show-up for a scheduled appointment with less than 24 hour notice will be charged the following:

- Cancellation or rescheduling of an appointment with 48 hours notice or more notification-no charge

- $50 per hour for a hygiene appointment - $75 per hour for a doctor's appointment

Every effort is made to contact patients to confirm. Our staff will contact you 2 days prior to your scheduled appointment to confirm with you. Please understand that this is a courtesy call, text, or email. DO NOT DEPEND ON THIS. If we are unable to reach you, your appointment card will serve as your confirmation of the appointment and implies your obligation to be present.
FINANCIAL POLICY

We accept cash, checks, money orders, Care Credit, and all major credit cards (Visa, MasterCard, American Express, Discover, FSA/HSA). Although we do accept the assignment of most insurance companies, your insurance is an agreement between you and your insurance company. We will do our best to see that you receive your full benefits. Payment for dental service is expected and required at the time of service, unless other arrangements have been made. There is a $35 fee for any check payment returned for nonpayment.
LATE PATIENT POLICY

Patient who arrive more than fifteen (15) minutes late to their scheduled appointment time may be asked to reschedule as a courtesy to our other scheduled patients.
By signing below, I acknowledge that I have read and understand this form.
Signature*

Clear
Date*

MonthDayYear
Date
PRIVACY PRACTICES ACKNOWLEDGEMENT (HIPPA)

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability And Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:

Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment); Obtaining payment from third party payers (e.g. my insurance company)? The day to day healthcare operations of your practice.

I have also been informed of, and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.

I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.

I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.
I have read and understand and acknowledge my HIPPA rights.
Signature*

Clear
Date*

MonthDayYear
Date
CONSENT FOR DENTAL PROCEDURES

I authorize Slone Dental and/or such associates or assistants as they may designate to perform procedures necessary or advisable to maintain my dental health or the dental health of any minor or other individual for which I have responsibility, including arrangement and/or administration of any sedation ( including nitrous oxide ), therapeutic, and or other pharmaceutical agent(s), including those related to restorative, pallative, therapeutic or surgical treatments. I understand that these may cause allergic reactions causing redness and swelling of tissues, pain, itching, vomiting, and/or anaphylactic shock with severe allergic reaction.

I understand the administration of local anesthetic may cause an untoward reaction or side effects, which may include but not limited to bruising, hematoma, cardiac stimulation, muscle soreness, and temporary or rarely, permanent numbness.

I understand during my course of treatment the following care may be provided but not limited to: Examinations, Preventative Services, X-Rays, Restorations, Root Canals, Crowns, Veneers, Bridges, Dentures, Extractions, Periodontal Treatments and/ or Bite Appliances.

I understand during treatment it may be necessary to change or add procedures because of conditions found during treatment that were unforeseen during examination, the most common being root canal therapy following routine procedures.

I understand it is important that I provide my dentist and their staff with accurate information before, during and after treatment. I understand it is equally important that I follow the advice and recommendations from my dentist and their staff regarding medication, pre and post treatment instructions, referrals to other dentists or specialists, and return for my scheduled appointments. If I fail to follow their advice , it may increase the chances of a poor outcome to my oral health and/or my overall health.

By signing below, I acknowledge that I have read and understand this form. I authorize Slone Dental to provide recommended treatment and I agree to assume the risks and inconveniences of my treatment.
Signature*

Clear
Date*

MonthDayYear
Date
Please state your relationship to the patient, if applicable: (ie. mother, father, legal guardian)
Please submit your answers now and we look forward to seeing you soon !!!!!
Should be Empty:

Slone Dental New Patient Form

Primary Insurance Information

Health History / Medical Alerts:

Dental History

Slone Dental Office Policies