• New Patient Form

  • Patient Registration

  • Contact

  • Date of Birth*
     - -
  • Format: (000) 000-0000.

  • Responsible Party

  • Date of Birth
     - -
  • Employed?
  • Format: (000) 000-0000.
  • ls this Person Currently a Patient in our Office?

  • Insurance Information

    Insurance (if applicable)
  • Do you have Insurance?*
  • Format: (000) 000-0000.

  • Second Insurance (if applicable)

    Only fill out if you have a secondary insurance plan
  • Format: (000) 000-0000.
  • Insured Birth Date
     - -

  • Signature

  • If this office accepts my insurance, I understand, that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment directly to the dental office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment. I hereby authorize release of any information, including the diagnosis and records of treatment or examination required, to my insurance company.

  • Date*
     - -

  • Medical History

  • Welcome

    The benefits of a happy, healthy smile are immeasurable! Our goal is to help you reach and maintain maximum oral health. Please fill this form out completely so that we can provide optimal care for you.

  • About You Medically

  • Do you have a personal physician?
  • Date of Last Visit*
     - -
  • Are you currently under the care of a physician?*
  • Have you ever been hospitalized/or had any surgical operation or serious illness within the last 5 years?*
  • Are you taking any Prescription/over-the-counter or herbal supplemental drugs?*
  • Do you take, or have you taken, Phen-Fen or Redux?*
  • Do you smoke or use tobacco in any other form?*
  • Are you wearing contact lenses?*

  • Allergies

  • Do you have any allergies?

  • Women: Are you...

  • Pregnant/Trying to get pregnant
  • Nursing?
  • Taking Oral Contraceptives?

  • Medical History

  • AIDS/HIV Positive
  • Anemia
  • Asthma
  • Artificial Heart Valve
  • Artificial Joint
  • Blood Disease
  • Blood Transfusion
  • Cancer
  • Congenital Heart Disorder
  • Cortisone Medicine
  • Diabetes
  • Easily Winded
  • Emphysema
  • Epilepsy or Seizures
  • Excessive Bleeding
  • Heart Attack/Failure
  • Heart Pacemaker
  • Heart Murmur
  • Heart Trouble/Disorder
  • Hepatitis A
  • Hepatitis B or C
  • Hemophilia
  • High Blood Pressure
  • Leukemia
  • Liver Disease
  • Mitral Valve Prolapse
  • Osteoporosis
  • Pain in Jaw Joints
  • Radiation Treatments
  • Renal Dialysis
  • Stroke
  • Thyroid Disease
  • Tonsillitis
  • Tuberculosis
  • Have you ever had any serious illness not listed above?*

  • Dental History

  • Allergies?
  • Do you require antibiotics before treatment?
  • Are you currently in pain?
  • Have you ever had a serious / difficult problem associated with any previous dental work?
  • Have you ever had gum treatment?
  • Your current dental health is
  • Do your gums bleed?
  • Do you like your smile?
  • What type of bristles does your toothbrush have?
  • Is any part of your mouth sensitive to temperature or pressure?

  • COVID-19 - Patient Consent and Disclosures

  • This patient disclosure form seeks information from you that we must consider before making treatment decisions during the COVID-19 virus outbreak

    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.

    The following questions apply to anyone entering our office. If you have multiple children, only one form is required for the family.

  • Do you have a fever or above normal temperature?*
  • Have you experienced shortness of breath or had trouble breathing?*
  • Do you have a dry cough?*
  • Do you have a runny nose?*
  • Have you recently lost or had a reduction in your sense of taste or smell?*
  • Do you have a sore throat?*
  • Have you been in contact with someone who has tested positive for COVID-19?*
  • Have you tested positive for COVID-19?*
  • Have you been tested for COVID-19 and are awaiting results?*
  • Have you traveled outside the United States by air or cruise ship in the past 14 days?*
  • Have you traveled within the United States by air, bus or train within the past 14 days?*
  • Have you been fully vaccinated against the disease known as COVID-19 caused by the Coronavirus?*

  • I am not aware of any risk whereby I might be infected or a possible carrier of COVID-19. I confirm that I have not tested positive for COVID-19 in the last 30 days and that I am not presenting any of the previously stated symptoms of COVID-19

    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 that may result in a compromised immune system.

    I understand that JH Dental and Braces is observing the guidelines from the Centers for Disease Control and Prevention for its recommended treatment and infection control protocols, and I willingly and knowingly consent to dental treatment by JH Dental and Braces, including any designated associates and team members during the COVID-19 pandemic.

    By signing this document, I acknowledge that the answers I have provided, and the statements above, are true and accurate.

  • Authorization and Release 

  • I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such Dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

  • Date*
     - -

  • HIPAA and Privacy Practices

  • Patient Acknowledgement of Receipt of Notice of Privacy Practices Pursuant to HIPAA and Consent of Use of Health Information

    The undersigned does hereby acknowledge that they have received a copy of this office's Notice of Privacy Practices pursuant to HIPAA and has been advised that a full copy of this office's HIPAA Compliance leaflet is available upon request. The undersigned does hereby consent to the use of their health information in a manner consistent with the Notice of Privacy Practices pursuant to HIPAA, the HIPAA Compliance leaflet, State law and Federal law.

    If the undersigned is a parent or guardian of the patient, they do acknowledge and consent to the above paragraph on behalf of the patient.

  • Date*
     - -

  • For more information, contact:
    The U.S. Department of Health & Human Services
    Office of Civil Rights
    200 Independence Avenue, S.W.
    Washington, D.C. 20201
    (877) 696-6775 (toll-free)

  • Cancellation Policy 

  • Our office reserves the right to charge a cancellation fee of $40.00 for all reserved appointments missed or canceled without a 48 hour's notice.

  • Date*
     - -

  • Acknowledgement of Patient Payment Responsibility 

  • I understand that the office of Dr. Jeffrey W. Henkes will bill my insurance for all appropriate dental treatment as a courtesy. I understand that I am responsible for all estimated co-pays at the the time of treatment. Any fees that are not paid by my insurance company will become my responsibility. Insurance policies and agreements are between the policy holders (patients) and their insurance companies. Any disputes of dental benefits are between these two parties. The dental office will help and support patients with disputed fees with their insurance companies, however, if an insurance balance is not paid within 60 days, the patient will assume responsibility of the balance on their account.

  • Date
     - -
  • Should be Empty: