eastlakedentalexcellence.com - New Patient Form

Patient Information

This information will be sent to your provider and will be kept as part of your patient records.
Name

First NameMiddle NameLast Name
Spouse/Parent
Home address
Zip
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Driver’s License #
Social Security #
Date of birth

MonthDayYear
Date
Mobile Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
HOW DID YOU HEAR ABOUT US?

Friend/RelativeGoogle ReviewOffice is close to my houseNewsletterI saw the office from the roadInternetMailerOther
Preferred Pharmacy Information
Name of Pharmacy
Phone Number of Pharmacy
Please enter a valid phone number.Format: (000) 000-0000.
Address of Pharmacy
DENTAL BENEFIT (INSURANCE)

Please fill out the following information IF you have a primary dental benefit plan.
Name of Insured Person
Relationship
Insurance company
Member ID
Policy #
Name of Employer
Have you been to a dentist this year?
Please be advised that our contract with your insurance company requires proper notification of your dental benefit responsibility. By signing this form you agree that any and all amounts denied for coverage for any reason is your responsibility. Our practice will not write off any denied or uncovered fees. It is required that we receive your consent to this before we can accept your insurance into our practice. Thank you for your cooperation.
Please initial
Signature of patient
Date

MonthDayYear
Date
CONFIRMING APPOINTMENTS
We know you are busy. We would like take the opportunity to confirm your appointments by text, email and/or phone calls with your permission. By checking each box you are giving the office permission to confirm your appointments by text and email.

Confirm my appointments via text messages?Confirm my appointments via email?
CANCELLATION POLICY
We know your time is limited and we appreciate your cooperation in minimizing scheduling conflicts. If you need to reschedule call us with at least 48 hour notice. We reserve the right to charge for appointments cancelled or broken without a 48-hour notice. Fees range from $35 up to cost of treatment scheduled for that day.

I have read the cancellation policy and I understand I am required to give 48hr notice for any rescheduling needs. By signing this I agree to pay any broken appointment fees I may acquire.
Please initial
Signature of patient
Date

MonthDayYear
Date
MEDICAL HISTORY
Are you under the care of a physician?

YesNo
Physician’s Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Last Exam
Specialty
Physician’s Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Last Exam
Specialty
Have there been any changes to your general health in the past year?

YesNo
Do you have any allergies?

YesNo
If yes, please indicate what you are allergic to:
Have you had any major illness, operation or been hospitalized in the past 5 years?

YesNo
If yes, please explain:
Have you had any abnormal bleeding or do you bruise easily?

YesNo
Have you ever required a blood transfusion?

YesNo
Do you use any marijuana products?

YesNo
Do you use any tobacco products?

YesNo
Do you have or have you had any of the following (please select and describe fully under remarks)?

Rheumatic FeverHigh Blood PressureHeart MurmurBacterial EndocarditisCongenital Heart ProblemProsthetic Joint/ImplantKidney TroubleAre you on Dialysis?AnginaType I DiabetesType II DiabetesHigh CholesterolSwollen AnklesArthritis or Joint DiseaseOsteoporosis/OsteopeniaStrokeOsteonecrosisStomach UlcersHIVEpilepsyChronic CoughCancerChemotherapyRadiationChronic FatigueAlcohol AbuseDrug AbuseGlaucomaMental health problems/ anxiety/ depressionPain and clicking of jaws when eatingThyroid troubleHeart AttackIrregular heart beatPacemakerAsthmaSinus ProblemsSleep ApneaBreathing difficultiesEmphysemaBlood transfusionBruise easilyAnemiaEating disorderAbnormal bleedingHepatitis, jaundice or liver diseaseNone
Remarks:
WOMEN ONLY
Are you pregnant or think you may be pregnant?

YesNo
Are you nursing?

YesNo
Are you taking birth control pills?

YesNo
MEDICATIONS LIST
MEDICATION/ DOSE/ HOW OFTEN?/ TREATMENT FOR.../ SPECIAL INSTRUCTIONS FOR MEDICATION? *
AUTHORIZATION AND RELEASE: I certify that I have read and understand the above information to the best of my ability. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health.
Please initial
Signature
Date

MonthDayYear
Date
DENTAL HISTORY
How would you rate the condition of your mouth?

ExcellentGoodFairPoor
Date of your most recent dental exam?

MonthDayYear
Date
Name of dentist
I routinely see my dentist every

3mo6mo9mo12moNot routinely
What is your immediate concern?
How fearful of dental treatment are on a scale of 1 (least) to 10 (most)?

1

2

3

4

5

6

7

8

9

10

1 is Least, 10 is Most
PERSONAL HISTORY
1. Have you ever had an unfavorable dental experience?

YesNo
2. Have you ever had complications from past dental treatment?

YesNo
3. Have you ever had trouble getting numb or had any reactions to local anesthetic?

YesNo
4. Did you ever have braces, orthodontic treatment or had your bite adjusted?

YesNo
5. Have you had any teeth removed?

YesNo
SMILE CHARACTERISTICS
6. Is there anything about the appearance of your teeth that you would like to change?

YesNo
7. Have you ever whitened your teeth?

YesNo
8. Have you felt uncomfortable or self conscious about the appearance of your teeth?

YesNo
9. Have you been disappointed with the appearance of previous dental work?

YesNo
BITE AND JAW JOINT
10. Do you have problems with your joint? (pain, sounds, limited opening, popping)

YesNo
11. Do you/would you have any problems chewing gum?

YesNo
12. Do you/would you have any problems chewing bagels, baguettes, protein bars, or other hard foods?

YesNo
13. Have your teeth changed in the last 5 years, become shorter, thinner or worn?

YesNo
14. Are your teeth crowding or developing spaces?

YesNo
15. Do you have more than one bite and squeeze to make your teeth fit together?

YesNo
16. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?

YesNo
17. Do you clench your teeth in the daytime or feel soreness in your jaw by the end of the day?

YesNo
18. Do you have any problems with sleep or wake up with an awareness of your teeth?

YesNo
19. Do you wear or have you ever worn a bite appliance?

YesNo
TOOTH STRUCTURE
20. Have you had any cavities within the past 3 years

YesNo
21. Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?

YesNo
22. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?

YesNo
23. Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth?

YesNo
24. Do you have grooves or notches on your teeth near the gum line?

YesNo
25. Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?

YesNo
26. Do you frequently get food caught between any teeth?

YesNo
27. Do your gums bleed or are they painful when brushing or flossing?

YesNo
GUM AND BONE
28. Have you ever been treated for gum disease or been told you have lost bone around your teeth?

YesNo
29. Have you ever noticed an unpleasant taste or odor in your mouth?

YesNo
30. Is there anyone with a history of periodontal disease in your family?

YesNo
31. Have you ever experienced gum recession?

YesNo
32. Have you ever had any teeth become loose on their own (without injury), or do you have difficulty eating an apple?

YesNo
33. Have you experienced a burning sensation in your mouth?

YesNo
NOTICE OF PRIVACY PRACTICES
I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPPA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
- Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
- Obtain payment from third-party payers.
- Conduct normal healthcare operations such as quality assessments and physician certificates.
I have received, read and understand your Notice of Privacy Practices containing a more complete descriptions of the uses and disclosures of my health information. I understand this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy. I understand I have the right to revoke this consent by giving a written request. I also understand you (East Lake Dental Excellence) are not required to agree to my requested restrictions and may not be able to continue treatment.
Please initial
Printed name
Date

MonthDayYear
Date
FINANCIAL AGREEMENT
It is customary that payment is due on the day that services are rendered. You will be given an estimate of the costs of treatment. If you have any questions concerning the quoted fees, or the explanation of benefits (EOB), please feel free to call for clarification.
INSURED PATIENTS
We will be happy to process your insurance forms as a service to you. We do require that you furnish our office with all of the necessary insurance information, if you wish us to file your insurance claim for you.
Initial
INSURANCE BENEFIT
All insurances are not the same, benefits differ from company to company and there are often different plans within the same insurance company. Some plans cover as little as 30% and some as much as 100% of covered services (most insurance companies fall in the 50-80% range). The insurance contract is between the patient, the employer, and the insurance company.
Initial
USUAL AND CUSTOMARY
Patients should be aware that some insurance companies will only pay claim percentages based on their evaluation of what is “usual and customary” (UCR) and not on the actual fee charged. Many companies often only update UCR once every 5-10 years.
Initial
PRE-AUTHORIZATION
It is the patient’s responsibility to inform us if their insurance company requires a pre-authorization before intended treatment. This takes about 4 weeks and will give all parties a more clear idea of the insurance payment.
Initial
ACCOUNT BALANCE
The balance of the account is solely the patient’s responsibility. It is due in full within 60 days of services rendered, regardless of any previously paid co-payment and/or outstanding insurance claims. A finance charge of 1.5% monthly may be assessed for accounts over 60 days. We suggest you contact your insurance company if payment has not been made within 40 days from the date of services. All patients with outstanding balances will receive a statement every 30 days.
Initial
RETURNED CHECKS
If your check is returned for non-sufficient funds, a $45 processing fee will be debited from your patient account. The use of a check for treatment is your acknowledgement and acceptance of this policy and its terms and conditions.
Initial
I have read this agreement and fully understand its content. I understand that I am responsible for all charges regardless of my insurance coverage.
Initial
Signature
Date

MonthDayYear
Date
Please Print Name
Relationship to Patient
Should be Empty:

Patient Information

Preferred Pharmacy Information

DENTAL BENEFIT (INSURANCE)

CONFIRMING APPOINTMENTS

CANCELLATION POLICY

MEDICAL HISTORY

WOMEN ONLY

MEDICATIONS LIST

DENTAL HISTORY

PERSONAL HISTORY

SMILE CHARACTERISTICS

BITE AND JAW JOINT

TOOTH STRUCTURE

GUM AND BONE

NOTICE OF PRIVACY PRACTICES

FINANCIAL AGREEMENT