New Patient Form | Montclair Smile Design

New Patient Information
Patient's Name*

FirstMiddleLast
Nickname (if applicable)
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone Number
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Email*
How do you prefer to receive appointment reminders? (check all that apply)*

Home PhoneWork PhoneCell PhoneText (Via Cell Phone)Email
Birthdate*

MonthDayYear
Age*
Gender*

MaleFemaleN/A
Occupation
Employer
Parent/Guardian Name (if patient is a minor)
Policy Holder Information
Name

FirstMiddleLast
Marital Status

SingleMarried
Address

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone Number
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Social Security Number
Birthdate

MonthDayYear
Relationship to Patient
Employer
Member ID#
Hire Date

MonthDayYear
Insurance Company
Group #
Secondary Insurance (if applicable)
Subscriber Name
Social Security Number
Birthdate

MonthDayYear
Relationship to Patient
Employer
Member ID#
Hire Date

MonthDayYear
Insurance Company
Group #
Emergency Contact
Emergency Contact Relationship to Patient
Emergency Contact Phone Number
Please enter a valid phone number.
Dental Information
Do you have bleeding or sore gums?*

YesNo
Do you grind or clench your teeth?*

YesNo
Do you notice jaw clicking or popping?*

YesNo
Any swelling or lumps in your mouth?*

YesNo
Are your teeth sensitive to hot or cold?*

YesNo
Are your teeth sensitive to pressure?*

YesNo
Are your teeth sensitive to sweets?*

YesNo
Do you have any fear of dental treatment?*

YesNo
Date of last dental exam:

MonthDayYear
Date
Last full-mouth x-rays taken:

MonthDayYear
Date
Previous Dentist Name
Reason for today's visit?*
What concerns do you have about your oral health or appearance of your teeth?
Medical Information
Have you been a patient in the hospital during the past two years?*

YesNo
Have you been under the care of a medical doctor during the past two years?*

YesNo
Physician’s Name
Physician's Phone Number
Please enter a valid phone number.
Please list any medications currently being taken:*
Are you allergic to or have you had a reaction to any of the following? (check all that apply)*

AspirinLocal anesthetic (Novocaine or Xylocaine)ErythromycinCodeineDemerolTetracyclineLatexPenicillinVicodinValiumSulfa DrugsN/A
Are you allergic to any other drugs?
Are you allergic to or have you had a reaction to any of the following? (check all that apply)*

Chest pain (angina)Blood in stoolsFrequent vomitingFainting spellsDiarrhea or constipation (within last 2 weeks)JaundiceRecent significant weight lossFrequent urinationDry mouthFever (within last 2 weeks)Difficulty urinatingExcessive thirstNight sweatsRinging in earsDifficulty swallowingPersistent coughHeadachesSwollen anklesCoughing up bloodDizzinessJoint pain or stiffnessBleeding problemsBlurred visionShortness of breathBlood in urineBruise easilySinus problemsN/A
Have you had or do you have any of the following? (check all that apply)*

Heart diseaseHospitalizationAsthmaFamily history of heart diseaseDiabetesHepatitisHeart attackFamily history of diabetesSexual transmitted diseaseArtificial jointTumors or cancerHerpesStomach problems or ulcersChemotherapyCanker or cold soresHeart defectsRadiationAnemiaHeart murmursArthritis, rheumatismLiver diseaseRheumatic feverEmphysema or other lung diseaseEye diseaseSkin diseaseKidney or bladder diseaseTransplantsHardening of arteriesStrokeTuberculosisHigh blood pressureEating disordersAIDS/HIVSeizuresOsteoporosisAnxiety or DepressionN/A
If you have or had any disease, condition or problem not listed please list:
Are you taking or have you taken any of the following in the last three months? (check all that apply)*

Tobacco in any formBisphosphonate (Fosamax)Fen-PhenRecreational drugsAlcoholN/A
Are you or could you be pregnant?*

YesNo
If yes, what month?
Are you nursing?*

YesNo
Are you taking birth control pills?*

YesNo
The practice of dentistry involves treating the whole person. If the dentist determines that there may be a potentially medically-compromised situation, medical consultation may be needed prior to commencement of dental treatment. I authorize the dentist to contact my physician. I certify that I have read and understand this form. To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medications. Further, I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form.
Signature of Patient, Parent or Guardian*

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Date*

MonthDayYear
Date
Signature of Dentist

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Date

MonthDayYear
Date
Records Release Authorization
Patient Name*

First NameLast Name
Iname*, request and authorizeprevious dentist* to disclose and provide copies of any and all clinical treatment records and information concerning my care in their possession to: Dr. Dhillon M.A. DDS & Dr. Sandhu M.S. DDS.
Previous Dentist Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Previous Dentist Phone Number*
Please enter a valid phone number.
These records include, but are not limited to, personal patient information. Medical and dental histories, exam and treatment records, radiographs, clinical photographs, referral and consultation recommendations and reports, diagnostic models and related materials. I release from liability the above named (“previous dentist”) from any and all liability arising from compliance with this request and disclosures of the requested information.
Signature of Patient, Parent or Guardian*

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Date*

MonthDayYear
Date
Financial Policy
We are committed to providing our patients with the best dental care possible. Included in that commitment is an open dialogue of our fees and financial policies. This agreement provides a written statement of our policies and procedures. Please review the following information. If you have any questions, please discuss this information with the doctor or his representative.

1. Payments. Payment is due at the time of service. For your convenience, we offer payment options in addition to cash and checks, including credit card payments.

2. Dental Insurance. Your insurance policy is a contract between you and your insurance
company. As health care providers, we are not a party to that agreement. We want to emphasize that our relationship is with you, not your dental benefit provider. There are no guarantees of Dental insurance benefits. If your insurance does not cover all or part of the treatment provided, you will be responsible for payment of fees which are not reimbursed by insurance. However, we are committed to helping our patients maximize their benefits. If you have PPO dental insurance, we will complete and submit a claim form to your benefit provider as a courtesy to you, and your insurance provider will reimburse you based on your benefits.

3. Treatment Plan Estimate. Once we have assessed your dental condition, we will present you with a written treatment plan. The treatment plan includes a detailed estimate of each procedure’s total fee, separated by the expected benefit portion and the patient’s obligation. Please note that the dental benefits are subject to various limits as determined by your benefit provider. All co-payments are due at the time of service. The estimate of fees is guaranteed for sixty (60) days. After such time, the fees are subject to change.

4. Returned Checks. Patients writing checks that are returned for any reason are subject to a “return check charge” of $35.00.

5. Canceled Appointments. As a courtesy to our patients, we will remind our patients of their appointments by telephone. Once an appointment has been made, this scheduled time has been reserved for you. We understand that circumstances arise that may prevent you from making your scheduled appointment. However, please note that should you fail to show for your appointment or fail to cancel your scheduled appointment within twenty four (24) hours of the scheduled appointment time, you may be subject to a charge of $150.00

I have reviewed the above terms and agree to be fully responsible for payment of treatment provided by this office. I authorize this office to file claims to my insurance carrier on my behalf. In addition, I give Montclair Smile Design permission to retain and charge my credit card on file for any outstanding balance resulting from the treatment rendered by the office.
Signature*

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Date*

MonthDayYear
Date
Should be Empty:

New Patient Information

Policy Holder Information

Secondary Insurance (if applicable)

Dental Information

Medical Information

Records Release Authorization

Financial Policy