Patient Information

Patient Information
Date*

MonthDayYear
Date
Patients Name*

First NameLast Name
Preferred Name*
Male/Female*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Age*
Birth Date*

MonthDayYear
Date
Social Security #
Cell #*
Format: (000) 000-0000.
E-mail address*
example@example.com
Additional Contact #
Format: (000) 000-0000.
If patient is a minor, give parent's or guardian's name.*
How did you hear about our office?*
Has any member of your family been at this office before? Names:*
Medical History
Heart Murmur*

YesNo
Hepatitis/Liver Disease*

YesNo
Rheumatic Fever*

YesNo
Kidney Disease*

YesNo
Asthma*

YesNo
Diabetes*

YesNo
Heart Disease*

YesNo
Epilepsy*

YesNo
Lung Disease*

YesNo
Scarlet Fever*

YesNo
Thyroid Disease*

YesNo
Nervous Disorder*

YesNo
High Blood Pressure*

YesNo
AIDS / HIV +*

YesNo
Metallic Implant*

YesNo
Tuberculosis*

YesNo
Glaucoma*

YesNo
Cold Sores/ Fever Blister*

YesNo
Blood Transfusion*

YesNo
Bleeding Gums*

YesNo
Women: Are you Pregnant Now?*

YesNo
Injury to Front Teeth*

YesNo
Tumor/Cancer*

YesNo
Bad Breath*

YesNo
Prolonged Bleeding When Cut*

YesNo
Stained tooth*

YesNo
Have you taken osteoporosis meds?*

YesNo
Latex or Metal Allergy*

YesNo
Have you taken Fen Phen, Redux or similar?*

YesNo
Tobacco/Marijuana*

YesNo
Please list any food or drug allergies.
Please list all current medications.
Please list any vitamins or herbal supplements regularly taken.
Has the patient recently been under the care of a physician? If yes, for what reason?
Name of medical doctor for above reason
Has the patient been hospitalized in the past five years? If yes, please explain.
Has the patient had a serious illness or operation? If yes, please explain.
Does the patient suffer from headaches? If yes, how often and how severe?
Important Note: I will immediately inform the doctor if there are any changes in the medical history.
Patient/Guardian Signature*
Date*

MonthDayYear
Date
Reviewed*
Date*

MonthDayYear
Date
Dental History
Last Dental Care: Date
Dentists Name
Address
Nature of Dental Care Provided
Responsible Party Information
Name*
Birth Date*
Social Security #
Address*
Phone*
Format: (000) 000-0000.
Employer*
Occupation*
Employer's Address*
Work Phone
Format: (000) 000-0000.
Spouse's Name
Birth Date
Social Security #
Spouse's Address (if different)
Phone
Format: (000) 000-0000.
Spouse's Employer
Occupation
Employer's Address
Work Phone
Format: (000) 000-0000.
Dental Insurance Information
Insured's Name
Insured's Soc. Sec. #
Insurance Company
Group #
Phone #
Format: (000) 000-0000.
Insurance Co. Address
Do you have dual Coverage?

YesNo
If yes:
Insured' Name
Insured's Soc. Sec. #
Insurance Company
Group #
Phone #
Format: (000) 000-0000.
Insurance Co. Address
Insured's Employer
Emergency Information
Name of nearest relative not living with you.*
Phone*
Format: (000) 000-0000.
Complete Address*
Consent*

I give my consent for Dr. Patel to do a complete/emergency oral and dental examination on the patient named previously. X-rays that are necessary to properly complete the exam may be taken. If a cleaning, fluoride treatment, and oral hygiene instruction are to be included in the first examination, I will be informed. Any additional dental treatment received will be fully explained prior to starting treatment.
Consent*

I understand that I am fully responsible for the cost of any treatment carried out regardless of insurance.
Additional Comments:
I have also received a copy of the Dental Materials Fact Sheet.
Signed*
Date*

MonthDayYear
Date
Financial Policy
Please understand that payment of your bill is considered a part of your commitment to treatment in our office. For your convenience, we accept cash, checks, and all major credit cards. For extensive treatment plans, we offer no interest payment options through Care Credit.
Regarding Insurance
For your convenience, we will process your dental claims with your insurance company. In return, we ask that you pay your deductibles and co-pays on the day treatment is rendered. Most insurances will not cover 100% of our fees. We will estimate the portion not covered by your insurance. Our estimates may differ from your insurance company's actual payment; therefore the amount due our office will be adjusted accordingly. The balance is your responsibility whether your insurance company pays or not. If your dental insurance does not pay their portion within 45 days of your treatment, you are responsible for full payment of the balance at that time. It is also your responsibility to inform us of changes in your insurance coverage.
Payment Options
1. We offer a 5% discount for your treatment if payment is made for the entire plan.
2. We accept cash, checks, and most credit cards
3. We offer outside financing through Care Credit.
4. We offer a 10% Senior Discount to patients 62 years or older who pay in full before treatment begins
Missed Appointments
Please help us serve better by keeping scheduled appointments. Missed or cancelled at the last minute appointments are unavailable to patients anxiously awaiting dental care. If the need to cancel a scheduled appointment arises, we request 48 hours notification. Appointments cancelled with less than 48 hours notice are subject to a $50 fee. Therefore, please consider your schedule carefully when making appointments.
Thank you for taking the time to read and understand our financial policy. Please let us know if you have any questions.
I have read the Financial Policy. I understand and agree to this Financial Policy.
Patient Signature/Responsible Party*
Date*

MonthDayYear
Date
Financial Arrangement
Patient Name:*
Treatment Plan:*
Total Estimated Fee:
Estimated Insurance Coverage:
Prepayment Savings:
Estimated Patient Portion:
Date*
Patient/Responsible Party*
Team Member*
Should be Empty:

Medical History

Dental History

Responsible Party Information

Dental Insurance Information

Emergency Information

Financial Policy

Regarding Insurance

Payment Options

Missed Appointments

Financial Arrangement