Dental Designs Boston
New Patient Dental Form
Welcome to our practice. Your comfort, health, and privacy are our top priorities. Please complete this form thoroughly. All information is confidential and compliant with HIPAA regulations
Patient Information:
Name
First Name
Last Name
Preferred Name:
Date of Birth
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Non-Binary
Prefer non to say
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Preferred Contact Method
Phone
Email
Emergency Contact:
Name
First Name
Last Name
Relationship to Patient
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance Information
Primary Insurance Company
Employer Name (If insurance is through employer)
Subscriber Name (If different from patient)
First Name
Last Name
Subscriber DOB (if different from patient)
Relationship to Patient
Self
Spouse
Parent
Other
Policy Number / Member ID
Group Number
Do you have Secondary Insurance?
Yes
No
If yes, provide details below
Medical History:
Please check all that apply or write additional information:
Heart Disease
High Blood Pressure
Low Blood Pressure
Joint Replacement
Diabetes
Bleeding Disorders
Stroke
Seizures
Asthma
Cancer / Radiation Treatment
Hepatitis A/B/C
HIV/ AIDS
Tuberculosis
Anxiety / Depression
Kidney Disease
Thyroid Problems
Other
List all medication you are currently taking:
Do you have any allergies? (Medications, latex, food, etc)
Are you currently pregnant or nursing?
Yes
No
Have you ever been advised to take antibiotics before dental treatment?
Yes
No
Dental History:
Last Dental Visit Date
Reason for today's visit
Have you ever experienced the following?
Tooth Sensitivity
Bleeding Gums
Jaw Pain / TMJ
Dry Mouth
Clenching / Grinding
Consent for Treatment:
I hereby authorize the dental team to perform diagnostic and treatment procedures as may be necessary for proper dental care. I understand that no guarantees have been made regarding the outcome of treatment. I understand I may ask questions and withdraw consent at any time.
Signature
Financial Agreement
I understand that I am financially responsible for all charges for services provided, regardless of insurance coverage. I authorize the release of any information necessary to process insurance claims and authorize payment of insurance benefits directly to the dental provider. I agree to pay all copayments and uncovered services at the time of service. Missed appointments without 24 hours' notice may incur a fee.
Signature
HIPPAA Acknowledgment
I acknowledge that I have received or been offered a copy of the practice's Notice of Privacy Practices, in compliance with HIPPAA regulations
I accept
I decline
Communication Consent
I consent to be contacted regarding appoitnments and treamtnet via:
Phone
Email
Text Message
All of the above
Photo and Video Consent (Optional)
I authorize the dental office to take photographs or videos of my treatment for documentation, education, or marketing purposes. Identifying features will be obscured unless specific permission is granted.
Yes
No
Thank you for your trust in our care. If you have any questions while completing this form, please ask our staff for assistance.
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