New Patient Form

New Patient Paperwork

7924 Cantrell Rd Little Rock, AR 72227 | 501-225-0113 | mylittlerockdentist.com
Patient Personal Information
Patient Name*

First NameLast Name
Nickname
Status

SingleMarriedWidowed
Date of Birth*

MonthDayYear
Date
SSN*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number*
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
How did you hear about us?*

PatientInternetWalk InFacebookOther
Responsible Party Information
Name*

First NameLast Name
Relation to Patient*
Date of Birth*

MonthDayYear
Date
SSN*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
In Event of Emergency
Emergency Contact*

First NameLast Name
Relation to Patient*
Emergency Contact Phone Number*
Please enter a valid phone number.
Dental Insurance Information
Primary Insurance*

YesNo
Insurance Company
Member ID #
Subscriber Name

First NameLast Name
Subscriber Date of Birth

MonthDayYear
Date
Relationship to Patient
Employer Name
Please take a photo of the FRONT of your Primary Insurance Card.
Please take a photo of the BACK of your Primary Insurance Card.
Secondary Insurance*

YesNo
Secondary Insurance Company
Member ID #
Subscriber Name

First NameLast Name
Subscriber Date of Birth

MonthDayYear
Date
Relationship to Patient
Employer Name
Please take a photo of the FRONT of your Secondary Insurance Card.
Please take a photo of the BACK of your Secondary Insurance Card.
Medical History
Are you currently under the care of a physician?*

YesNo
If yes, what is the condition being treated?
Have you had any serious illness, operation, or been hospitalized in the last five years?*

YesNo
If yes, please explain.
Do you have a pain management contract?*

YesNo
Do you require an antibiotic before dental work?*

YesNo
Do you use tobacco in any form?*

YesNo
If yes, what type and how often?
Do you consume alcohol?*

YesNo
If yes, how often?
Physician Name*
Physician Phone Number*
Please enter a valid phone number.
Pharmacy Name*
Pharmacy Phone Number*
Please enter a valid phone number.
Please list all prescription and over the counter medications you are currently taking:*
Allergies
Are you allergic to any of the following?*

AspirinCodeineDental AnestheticSulfaPenicillinLatexBarbiturates/SedativesOtherNone
Medical History
Do you have any of the following conditions?*

ADD/ADHDAIDS/HIVAnemiaAnaphylaxisAnemia/Blood DisorderArthritisArtificial Joints/ValvesAsthmaAutism/Sensory DisorderBisphosphonatesCancer/TumorCongenital Heart DefectDiabetes - Type 1Diabetes - Type 2Drug/Alcohol AbuseEating DisorderEmphysemaEpilepsy/FaintingFever BlisterFrequent HeadachesHeart AttackHeart MurmurHeart SurgeryHepatitisHigh/Low Blood PressureHypoglycemiaKidney ProblemsLiver DiseaseNeurologic ConditionOsteoporosisPacemakerPsychiatricRadiationSinus TroubleStrokeTuberculosisUlcersRespiratory IssueAcid RefluxNone
Women Only

Birth ControlNursingPregnant
Dental History
What prompted you to come to the dentist today?*
How long has it been since your last dental exam and cleaning? *
Who was your previous dentist?
How many times per day do you brush your teeth?*
How many days per week do you floss your teeth?*
Have you had any discomfort from your teeth or gums lately?*

YesNo
If yes, please explain.
Are you concerned with bad breath?*

YesNo
If yes, please explain.
Do you like your smile?*

YesNo
If yes, please explain.
Would you like your teeth to be whiter?*

YesNo
If yes, please explain.
Do your gums bleed when you brush or floss?*

YesNo
If yes, please explain.
Have you been previously diagnosed with periodontal disease?*

YesNo
If yes, please explain.
Have you previously had orthodontic treatment (braces)?*

YesNo
If yes, please explain.
Have your teeth recently shifted in position or alignment?*

YesNo
If yes, please explain.
Are your teeth sensitive to hot, cold, sweets?*

YesNo
If yes, please explain.
Do you currently have any dental implants, dentures, partials?*

YesNo
If yes, please explain.
Does food often get stuck between certain teeth?*

YesNo
If yes, please explain.
Does your jaw pop or click when you open or close your mouth?*

YesNo
If yes, please explain.
Do you habitually grind or clench your teeth?*

YesNo
If yes, please explain.
Do you now wear or expect to wear dentures someday?*

YesNo
If yes, please explain.
Do you have missing teeth you would like to get replaced?*

YesNo
If yes, please explain.
Do you habitually chew on anything?*

YesNo
If yes, please explain.
Do you frequently snack on sweets?*

YesNo
If yes, please explain.
Does going to the dentist give you anxiety?*

YesNo
If yes, please explain.
Have you ever had a particularly bad experience at the dentist?*

YesNo
If yes, please explain.
Have you ever had abnormal bleeding after surgery/trauma?*

YesNo
If yes, please explain.
Is there anything else about your dental history you would like us to know?
Payment and Dental Insurance Policy

I acknowledge that payment is due at the time of treatment, unless other arrangements have been made prior to treatment. I accept full financial responsibility for all charges for services or items provided to me, to my minor/child, or to the patient for whom I have legal responsibility. I understand that filing a claim with my insurance company does not relieve me from my responsibility from the payment of all charges incurred. As a courtesy to our patients, we will file most dental claims with your insurance company. For some insurance policies, we are able to estimate the benefits available to you with your specific policy. Our estimates are not a guarantee of payment and any balance resulting from a lower reimbursement from your insurance than initially estimated is due in full. In addition, if the insurance company fails to make payment, the entire balance may become due from the patient.
Please initial here to acknowledge the Payment & Dental Insurance Policy.*
Photo and Video Release

I recognize that, from time to time, Ake family Dentistry will take photos for reasons including but not limited to: Communications with dental labs, for use in peer discussions and studies, and Marketing/Advertising. I grant the right and permission to use photos/videos taken of me (or my child), or in which I (or my child) may be included individually or with others, to use, reuse, and publish, with media for purpose for illustrations, promotion, art, editorial, and advertising.
Please initial here to acknowledge the Photo and Video Release.*
Appointment Policy

In order to offer the best dental services to our patients, the office reserves individual appointment times for every patient. Should something occur that requires you to break your scheduled appointment, we ask that you give a minimum of 24 hours notice for any appointment changes or cancellations, yet earlier notification is greatly appreciated. We understand that unexpected events can occur but we ask that you do your best to arrive on time for your scheduled appointments. In the event you are late for your scheduled appointment, you may be asked to reschedule your appointment as time allows. After consecutive failed appointments, we reserve the right to not reschedule you for any further appointments.
Please initial here to acknowledge the Appointment Policy.*
Text and Email Policy

You may be contacted via email and/or text messaging, via the phone number/email provided to remind you of an appointment, to obtain feedback on your experience with our team, to provide general treatment reminders, and information about our clinic and services.
Please initial here to acknowledge the Text and Email Policy.*
Consent to Receive Treatment

Upon diagnosis, I authorize the doctor to perform all recommended treatment mutually agreed upon and to employ such assistance as required to provide proper care. I agree to the use of any necessary anesthetics, sedatives, and other medications. I fully understand that using any medications can involve certain risks. I understand that I can ask for complete recital of any possible complications.
Please initial here to acknowledge the Consent to Receive Treatment.*
Notice of Privacy Policy

We care about your privacy and the privacy of your personal health information. By law, we are required to maintain your privacy, and to give you notice of our privacy policies and practices, if requested.
Please initial here to acknowledge the Notice of Privacy Policy.*
Please list below any person who can receive PHI (Protected Health Information) on this patient.
Name

First NameLast Name
Relationship to Patient
Treatment Info

YesNo
Ledger

YesNo
Cancellation Policy
Dr. Ethan Ake and his staff are committed to your health. When you miss an appointment, other patients are unable to take your place and are delayed unnecessarily. If you are unable to keep an appointment, we ask that you cancel at least 24 hours in advance. Please call as soon as possible so that another patient can be given your appointment.

Our office tracks missed appointments. A “no show” or “late cancellation” is defined as missing or rescheduling an appointment without giving 24 hours of advanced notice. There will be a $50 charge for a missed appointment. Insurance will not cover charges for “no show” or “late cancellation” fees. This charge is in addition to any other charges you may have incurred.

Unfortunately, repeated missed appointments may result in a letter discharging the patient from the practice. Dr. Ake understands that emergencies will occur and consideration will be made for missed or no show appointments.

By signing below, you state that you have been notified and understand this policy,
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New Patient Paperwork

Patient Personal Information

Responsible Party Information

In Event of Emergency

Dental Insurance Information

Medical History

Allergies

Medical History

Dental History

Cancellation Policy