www.shinedentalteam.com - New Patient Form

  • New Patient Form

  • Personal Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Insurance

  • Will you be using dental insurance at your appointment?*
  • Format: (000) 000-0000.

  • Emergency Contact

  • Would you like to put an emergency contact in your chart?*
  • Format: (000) 000-0000.

  • Assignment and Release

  • I, {name} the undersigned, certify that I (or my dependent) have insurance coverage and assign directly to Shine Dental Arts 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 hereby authorize the doctor to release all information necessary to secure the payments of benefits. I authorize the use of this signature on all insurance submissions.

  •  - -

  • Consent

  • Will you be signing as self, parent, guardian, or health care agent (Medical Power of Attorney)?*
  • I consent to the diagnostic procedures and treatment by the dentist necessary for proper dental care.*
  •  - -

  • Medical History

  • Format: (000) 000-0000.

  • (if you are not under the care of physician, please put N/A and 0's for the phone number)

  • Have you had any joint replacements, heart surgery or implants?*
  • Has a doctor told you that you require antibiotic premedication before dental treatment?*
  • Are you taking any medications?*
  • Is there any chance that you are pregnant?*
  • Have you ever had any surgical procedures?*
  • Format: (000) 000-0000.

  • Conditions

  • Abnormal Bleeding*
  • Acid Reflux/ GI Disorders*
  • Anemia*
  • Asthma*
  • Arthritis*
  • Artificial Heart Valve*
  • Atrial Fibrillation*
  • Blood Clots*
  • Cancer*
  • Chemotherapy*
  • Congenital Heart Defects*
  • Dementia*
  • Diabetes*
  • Difficulty Breathing*
  • Drug Abuse*
  • Eating Disorders*
  • Emphysema*
  • Epilepsy/Seizures*
  • Facial Surgery*
  • Fainting Spells*
  • Frequent Headaches*
  • HIV+/AIDS*
  • Heart Attack*
  • Heart Murmur*
  • Hepatitis A*
  • Hepatitis B*
  • Hepatitis C*
  • High Blood Pressure*
  • Heart Valve Replacement*
  • Kidney Disease*
  • Liver Disease*
  • Pacemaker*
  • Parkinson’s Disease*
  • Psychiatric Disorder*
  • Radiation Therapy*
  • Seasonal Allergies*
  • Sinus Disorder*
  • Sleep Apnea*
  • Stroke*
  • Thyroid Disorders*
  • Tobacco/Vape*
  • Tuberculosis*

  • Allergies

  • Aspirin*
  • Codeine*
  • Dental Anesthetics*
  • Latex*
  • Metals*
  • Penicillin/Amoxicillin*
  • Sulfa*
  • Other*

  • Patient Acknowledgment and Certification

  • I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.

  •  - -

  • Dental History

  • Are you currently experiencing any pain in your mouth?*
  • Have you ever wanted to change the look of your smile?*
  • Have you ever had periodontal (gum disease) treatment?*
  • Do your gums bleed when you brush or floss?*
  • Do you snore or has anyone told you that you snore?*
  • Do you clench or grind your teeth?*
  • Have you ever wanted to change the spacing and arrangement of your teeth?*
  • Is there any additional information you would like to share regarding your previous dental office experience?*

  • Airway Obstruction Screening

  • At Shine Dental Arts, we screen our patients for any signs in the oral cavity of airway issues and also improper breathing that contribute to systemic disease in the body like high blood pressure and diabetes. This quick questionnaire aids us in that process of determining if there are any airway obstructions occurring on a consistent basis.

  • Please rate the following scenarios on how likely you are to fall asleep:
    0 = No Chance, 1 = Slight Chance, 2 = Moderate Chance, 3 = High Chance

  • Rows

  • Score: Add up your score: 0-10 Normal Range l 10-12 Borderline l 12-24 Sleep

  • Financial Policy

  • We appreciate that you have chosen Shine Dental Arts for your oral health care needs. We understand that every patient has unique financial situations, and we are here to help. To ensure clarity and comfort, here are the key points to our financial policy:

  • Thank you for understanding and cooperating with our financial policies. We're here to answer any questions you might have and to make your experience as smooth and pleasant as possible.

  •  - -

  • Patient Consent to Receive Mail, Text, and Telephone Messages

  • We utilize texting as a convenient and efficient method to communicate important information and reminders to our patients.

  • Do we have your permission to:

  • Send a recall appointment reminder to your phone/home?*
  • Leave appointment, billing or dental information on your answering machine, voicemail, text, or email?*

  • Consent to Share Information

  • Would you like to give permission to an individual for Shine Dental Arts to share your information with them?*

  • Acknowledgement of Receipt of Notice of Privacy Practices - HIPAA

  • We have our Notice of Privacy Practices for any patient requesting a copy at the front desk.

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  • Additional Requests

  • Should be Empty: