Updated Patient Paperwork

Updated Patient Paperwork

For Office Use Only
Date*

MonthDayYear
Date
Name*

First NameLast Name
Parent or Legal Guardian Name (if applicable)

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Social Security #*
Drivers License #
Email
Cell Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Contact Preference

CellTextEmail
Do you have a dental benefit plan?*

YesNo
If yes, Member ID Number
Group Number
Name of Policy Holder

First NameLast Name
Policy holder's relationship to the patient
Policy holder's birthdate

MonthDayYear
Date
Policy holder's employer
Insurance Company
Insurance company's address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Medical History
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Are you under a physician's care now?*

YesNo
If yes, name of physician
Have you ever been hospitalized or had a major operation?*

YesNo
Have you ever had a serious head or neck injury?*

YesNo
Are you taking any medications, pills, or drugs?*

YesNo
Do you take, or have you taken, Phen-Fen or Redux?*

YesNo
Have you ever taken Fosamax, Boniva, Actonel, or any other medications containing bisphosphonates?*

YesNo
Are you on a special diet?*

YesNo
Do you use tobacco?*

YesNo
Do you use controlled substances?*

YesNo
Women, are you...

Currently PregnantTrying To Get PregnantNursingTaking Oral ContraceptivesNone of the Above
Are you allergic to any of the following:*

AspirinMetalPenicillinLatexCodeineSulfa DrugsAcrylicLocal AnestheticsNoneOther
If other, please explain:
Do you have, or have you had, any of the following (check all that apply):*

AIDS/HIV PositiveAlzheimer's DiseaseAnaphylaxisAnemiaAnginaArthritis/GoutArtificial Heart ValveArtificial JointAsthmaBlood DiseaseBlood TransfusionBreathing ProblemsBruise EasilyCancerChemotherapyChest PainsCold Sores/Fever BlistersCongenital Heart DisorderConvulsionsYellow JaundiceCortisone MedicineDiabetesDrug AddictionEasily WindedEmphysemaEpilepsy or SeizuresExcessive BleedingExcessive ThirstFainting Spells/DizzinessFrequent CoughFrequent DiarrheaFrequent HeadachesGenital HerpesGlaucomaHay FeverHeart Attack/FailureHeart MurmurHeart PacemakerHeart Trouble/DiseaseHemophiliaHepatitis AHepatitis B or CHerpesHigh Blood PressureHigh CholesterolHives or RashHypoglycemiaIrregular HeartbeatKidney ProblemsLeukemiaLiver DiseaseMitral Valve ProlapseOsteoporosisPain in Jaw JointsParathyroid DiseasePsychiatric CareRadiation TreatmentsRecent Weight LossRenal DialysisRheumatic FeverRheumatismScarlet FeverShinglesSickle Cell DiseaseSinus TroubleSpina BifidaStomach/Intestinal DiseaseStrokeSwelling of LimbsThyroid DiseaseTonsilitisTuberculosisTumors or GrowthsUlcersVenereal DiseaseNone of the aboveOther
Have you ever had any other serious illness not listed above?*

YesNo
Is there anything else our office should know regarding your medical history?
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.
Signature*

Clear
Date*

MonthDayYear
Date
Acknowledgement of Receipt of Notice of Privacy Practices

*You may refuse to sign this acknowledgement*
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Confirm appointments by text message?

YesNo
Confirm appointments by email?

YesNo
Email Address
With whom may we share your Protected Health Information:
Name

First NameLast Name
Name

First NameLast Name
Name

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date
Hurricane Creek Dental strives to provide the best dental care at the most fair and reasonable cost to our patients. If you have dental insurance, we will file your dental claim as a courtesy. We will attempt to collect all that is legally due from your insurance company. However, our treatment fee contract is with you, it is not with your insurance company.

We will do our best to provide an accurate estimate of what insurance might pay, but cannot guarantee that your insurance will pay.

Most claims will be processed using the insurance's usual, customary, and reasonable fees, but due to the number of new policies within many of the existing networks, we cannot guarantee that your policy dictates as a fee write off will be honored, especially when treatment is down coded, denied completely, or your yearly benefits have been used.

I am aware that my dental insurance fee adjustment and write offs may not apply to my dental treatment and I agree to pay all fees to Dr. Blakely regardless of what insurance remits.
Signature*

Clear
Date

MonthDayYear
Date
Name if signed on behalf of patient

First NameLast Name
Appointment No Show & Cancellation Disclosure
Patients who are not able to keep their appointments are asked to provide timely notice of cancellation or need to reschedule prior to their appointment. Unfortunately, in recent months our "no show" rate for appointments has significantly increased. This has created multiple challenges, but most importantly, it is compromising our ability to provide care for our patients who need to be seen in a timely manner.

We will send automatic appointment reminders via email, text, telephone calls, etc. based on your communication preferences, but it is utimately your responsibility to remember your appointment date and time.

No Show:
A "no show" is defined as a scheduled appointment where you fail to arrive; or you are greater than 15 minutes late. If at any point there is a no show, the patient will be charged a fee of $25.

Late Cancellation:
A "late cancellation" is defined as a scheduled appointment that you fail to provide 24 hours notice of the cancellation. After the 3rd late cancellation, the provider reserves the right to dismiss care.

If you do not show for a new patient appointment, we will not reschedule that appointment.

Additionally, we ask that you arrive at least 10 minutes early for your New Patient appointment so that all your information can be transferred into your patient chart for your provider to start your appointment on time. We appreciate your consideration of other patient's time.

Please bring a list of your current medications and insurance information with you. Also please let us know if you have had any address of contact information changes since your last visit.

Patients under the age of 18 will be required to be accompanied by a parent or guardian.

Please sign and date below, acknowledging recognition of this policy.
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Updated Patient Paperwork

Medical History

Acknowledgement of Receipt of Notice of Privacy Practices

Appointment No Show & Cancellation Disclosure