Waterloo Patient Medical Dental Form

New Patient
Patient's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone
Cellular/Other*
Please enter a valid phone number.Format: (000) 000-0000.
Home
Please enter a valid phone number.Format: (000) 000-0000.
Work
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact
Name*

First NameMiddle NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.

Insurance Policy Information

Please provide us with your Insurance Benefits Card
YesNo
Primary InsuranceSecondary Insurance
Primary Insurance
Click or Upload the photoFill the details
Name of Policy Holder*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Insurance Company*
Policy / Group Number*
I.D. / Certificate Number*
Take a picture (front & back) or upload insurance card (OPTIONAL)*

Cancelof
Secondary Insurance
Click or Upload the photoFill the details
Name of Policy Holder*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Insurance Company*
Policy / Group Number*
I.D / Certificate Number*
Take a picture (front & back) or upload insurance card (OPTIONAL)*

Cancelof
Patient Consent For Electronic Insurance Claim Submission

Please review the following if you would like our office to process your dental insurance claims electronically.
I AUTHORIZE the release, to my dental benefits plan administer and the CDA, information contained in claims submitted electronically. I also AUTHORIZE the communication of information related to the coverage of services described to Dr. Ashish Thomas Kunnekel. This AUTHORIZATION shall continue in effect until the undersigned revokes the same.
Signature of Patient*
Patient's Name*

First NameMiddle NameLast Name
Signature Of Responsible Party*
Responsible Party's Name*

First NameMiddle NameLast Name
Date

MonthDayYear
Date

Rows	Yes	No
Bleeding Gums
Dental Senstivity
Tooth Pain/Swelling

Rows	Yes	No	Please Specify	Year	Dental Provider
Orthodontic

Rows	Yes	No
Does your child wear any occlusal appliance?
Does your child have any missing teeth?
Did your child have any trauma to jaw or teeth?

Rows	Yes	No	Please Specify	Year	Dental Provider
Orthodontic

Rows	Yes	No
Does your child wear any occlusal appliance?
Does your child have any missing teeth?
Did your child have any trauma to jaw or teeth?

Rows	Yes	No	Please Specify	Year	Dental Provider
Orthodontic

Rows	Yes	No
Does your child wear any occlusal appliance?
Does your child have any missing teeth?
Did your child have any trauma to jaw or teeth?

Rows	Yes	No	Please Specify	Year	Dental Provider
Orthodontic

Rows	Yes	No
Does your child wear any occlusal appliance?
Does your child have any missing teeth?
Did your child have any trauma to jaw or teeth?

Rows	Yes	No	Please Specify	Year	Dental Provider
Orthodontic

Rows	Yes	No
Does your child wear any occlusal appliance?
Does your child have any missing teeth?
Did your child have any trauma to jaw or teeth?

Rows	Yes	No	Please Specify	Year	Dental Provider
Orthodontic

Rows	Yes	No
Does your child wear any occlusal appliance?
Does your child have any missing teeth?
Did your child have any trauma to jaw or teeth?

Rows	Yes	No	Please Specify	Year	Dental Provider
Orthodontic

Rows	Yes	No
Does your child wear any occlusal appliance?
Does your child have any missing teeth?
Did your child have any trauma to jaw or teeth?

Rows	Yes	No	Please Specify	Year	Dental Provider
Orthodontic

Rows	Yes	No
Does your child wear any occlusal appliance?
Does your child have any missing teeth?
Did your child have any trauma to jaw or teeth?

Appointment & Office Policies
It is important to remember that your insurance policy is a contract between you, your employer and the insurance carrier. The patient is ultimately responsible for their account, and any discrepancy regarding reimbursement will be between the patient and the insurance carrier. It is also your responsibility to make sure of the validity of your dental benefit the day of the appointment.

When needed, we will prepare a treatment plan which will be sent to your insurance company. The insurer (you) will get an answer from the insurance by mail or email which you will be required to consult on your dental benefit’s website, as well as notify your dental office.

At the end of your appointments, please stop at the front desk and a receptionist will submit your claim electronically when permitted or print a claim form to sign. We will revise with you the treatment received. At this time, any balances will be presented to you and payment will need to be settled.

You are also responsible to inform our office of any changes regarding your dental benefit, address, telephone number and any changes in your health.

Our dental clinic requires a minimum of 72 hours notice to be rescheduled.
I Understand

I Understand
Patient's Signature*
Patient's Name*

First NameMiddle NameLast Name
Responsible Party's Signature*
Responsible Party's Name*

PrefixFirst NameMiddle NameLast Name
Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Should be Empty:

Rows	Yes	No
Latex
Food
Any Metals
Aspirin
Barbiturates / Sleeping Pills
Codeine
Penicillin
Sulfa Drugs
Local Anesthetic (Freezing)
Nitrous Oxide
Any Other Drugs
Any injection
Other

Rows	Yes	No
Glaucoma
Heart Murmur
Arthritis
Asthma
Heart or Blood Pressure Problems
Prosthetic or Artificial Joints
Any conditions or therapies that could affect your immune system, eg, leukemia, AIDS, HIV infection, radiotherapy, chemotherapy
Hepatitis, jaundice, or liver disease
Bleeding problem or bleeding disorder
Anemia or Leukemia
Have you ever been treated for or told to have Cardiovascular Disease? ( Heart attack / open heart surgery / stroke/ etc)
Diabetes

Rows	Yes	No
Angina
Chest Pain
Heart Attack
Stroke
Shortness of Breath
Rheumatic Fever
Mitral Valve Prolapse
Heart Murmur
Pacemaker
Lung Disease
Tuberculosis
Cancer
Steroid Therapy
Diabetes
Stomach Ulcers
Arthritis
Seizures (epilepsy)
Kidney disease
Thyroid Disease
Drug/alcohol dependency
Osteoporosis Medications (eg, Fosamax Actonel)

Responsible Party's Information

Existing Patient

Phone Number

Emergency Contact

Medical Update

Insurance Update

Primary Insurance

Secondary Insurance

Patient Consent For Electronic Insurance Claim Submission

New Patient

Telephone

Emergency Contact

Insurance Policy Information

Primary Insurance

Secondary Insurance

Patient Consent For Electronic Insurance Claim Submission

Medical Health History

Allergies

Medical Conditions

Dental History

Information Release

Family Member

Medical History

Information Release

Information Release

Information Release

Information Release

Information Release

Information Release

Information Release

Information Release

Appointment & Office Policies

Rows	Yes	No	Please specify Location
Bleeding Gums
Dental Senstivity
Tooth Pain/Swelling