BL Dental Miami - New Patient Form

Date*

Date

Email*

example@example.com

Home Phone*

Please enter a valid phone number.

Cell Phone*

Please enter a valid phone number.

Patient Name*

PrefixFirst NameLast Name

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Sex*

MF

Relationship*

Partnered For Years

Birthdate*

Date

Age*

Patient Employer/School*

Occupation*

Employer/School Address*

Street Address

Street Address Line 2

CityState

Zip Code

Employer/School Phone*

Please enter a valid phone number.

Whom May We Thank For Referring You?

ln Case Of Emergency Who Should Be Notified?*

Phone*

Please enter a valid phone number.

Is the patient covered by Insurance?*

YesNo

Are you the insurance policy holder?*

YesNo

Name of the Policy Holder*

PrefixFirst NameLast Name

Relation To Patient*

Birthdate*

Date

Address (If Different From Patient's)*

Street Address

Street Address Line 2

CityState

Zip Code

Insurance Company*

Contract #*

Group #*

Subscriber #*

ls Patient Covered by Medical Insurance?*

YesNo

Name of the Policy Holder*

Relation to Patient*

Birthdate*

Date

Address (lf Different From Patient's)

Street Address

Street Address Line 2

CityState

Zip Code

Insurance Company*

Contract #*

Group #*

Subscriber #*

Reason for Today's Visit*

Date of Last Dental Care

Date

Former Dentist

Date of Last Dental X-Rays

Date

Address

Street Address

Street Address Line 2

CityState

Zip Code

Check (✔) if you have had problems with any of the following:

Bad breathGrinding / clenching teethLoose teeth or broken fillingsClicking or popping jaw

Are your teeth sensitive to anything?

How often do you brush?

Physician's Name

Date of Last Visit

Date

Have You Had Any Serious Illnesses or Operations?*

YesNo

If Yes, Describe

Have You Ever Had a Blood Transfusion?*

YesNo

lf Yes, Give Approximate Dates

Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)*

YesNo

(Women) Are You Pregnant?

YesNo

Are You Nursing?

YesNo

Taking Birth Control Pills?

YesNo

Check (✔) if you have or have had any of the following:*

Please explain any medical problems, if applicable.

Are you currently taking any medications?*

YesNo

List medications you are currently taking:*

Do you have any allergies?*

YesNo

ALLERGIES:*

Have you ever been told you snore?*

YesNo

Have you ever dozed in a car after it stops for a few minutes in traffic?*

YesNo

Have you ever been given a CPAP recommendation?*

YesNo

Based on your responses above, you may be at risk for sleep apnea. Please complete the following portion of the form below.

How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired?*

	I would never doze	I have a slight chance of dozing	I have a moderate chance of dozing	I have a high chance of dozing
While sitting or reading ?
Watching TV
Sitting inactive in a public place (theater or meeting)
As a passenger in a car for an hour without a break?

Diagnosed or Treated*

History of StrokeMood DisordersInsomniaHypertension (high blood pressure)Impaired Cognition (i.e., difficulty concentrating or thinking)Ischemic Heart Disease (Coronary Artery Disease/Atherosclerosis)Obstructive Sleep Apnea (OSA), If yes did you try to use a CPAPGastric Reflux (GERD) or HeartburnNone of the Above

Are you completing this form for yourself or your child? *

Are you aware of (or have you been told):

	Yes	No	Not Sure
Snoring on a regular basis
Feeling tired or fatigued on a regular basis
Clenching or grinding your teeth (bruxism
Having frequent headaches
Your neck size being > 17 inches (male) or > 16 (female)
Anyone in your family having sleep apnea (OSA)
Stopping breathing when sleeping/awakening with a gasp

Do you notice any of the following about your child?

	Yes	No	Not Sure
Snoring/noisy breathing while sleeping
Grinding his or her teeth
Wetting the bed
Having difficulty in school/learning
Being treated for ADD/ADHD
Breathing primarily through their mouth
Having frequent nightmares/night terrors
Having frequent ear aches

I certify that I, and/or my dependent(s), have insurance coverage withName of Insurance Company(ies) and assign directly to Lizette Barzaga, DDS all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named dentist may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

I have read BL Dental Miami's HIPAA Acknowledgement and Financial Policy Forms, and agree to both.

Signature of Patient, Parent, Guardian or Personal Representative*

Date*

Date

Please print name of Patient, Parent, Guardian or Personal Representative*

Relationship to Patient

REGISTRATION AND TREATMENT

PATIENT INFORMATION

DENTAL INSURANCE

If you have a secondary insurance, please contact our office.

MEDICAL INSURANCE

DENTAL HISTORY

If you have x-rays from a different doctor, please email our office with them.

MEDICAL HISTORY

SLEEP APNEA

Epworth Sleepiness Scale (ESS)

Check all of the following that you have been diagnosed or treated for:

AUTHORIZATION

Payment is due in full at time of treatment unless prior arrangements have been approved.