• New Patient Paperwork

    Complete pages 1–4 with your personal, contact, insurance, and dental history details.

  • Page 1 · About the patient

  • This form is for:*
  • Today's date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Patient date of birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Sex
  • Marital status
  • Is the patient a child (under 18)?*
  • Is the patient a student?
  • Full-time or part-time

  • Page 2 · Contact information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Preferred method of communication
  • Were you referred to us?
  • Emergency contact
  • Format: (000) 000-0000.
  • Employment
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Page 3 · Dental insurance

  • Do you have dental insurance?*
  • Subscriber date of birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Patient relationship to subscriber*
  • Upload a File
    Drag and drop files here
    Choose a file
    Cancelof
  • Do you have secondary dental insurance?
  • Subscriber date of birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Patient relationship to subscriber*

  • Page 4 · Previous dentist and dental history

  • Format: (000) 000-0000.
  • Oral health
  • Are you currently having dental discomfort?
  • Any unhappy/unpleasant dental experiences?
  • Any injuries to mouth/teeth/head?
  • Does any type of dental treatment make you nervous?
  • Any missing teeth other than wisdom teeth or orthodontic extractions?*
  • Have missing teeth been replaced?*
  • Do you have any mercury/silver amalgam fillings?*
  • Received root canal therapy?*
  • Orthodontic appliances now or in the past?*
  • Gums bleed when brushing or flossing?*
  • Concerned about gum disease?*
  • History of gum disease?
  • Any concerns about the appearance of your teeth?*
  • Does it hurt to bite or chew?*
  • Does food catch between your teeth?*
  • Do you have tooth sensitivity to heat, cold, pressure or sweets?*
  • Do you have pain or clicking in the jaw joint in front of your ear?*
  • Have your jaw muscles ever been sore?*
  • Are there any sores or growths in your mouth?*
  • Do any of your teeth ache?*
  • Teeth shifted, new spaces between teeth, teeth flaring or loose teeth?*
  • Do you clench or grind your teeth?*
  • Do you wear a night guard or splint?
  • Do you want to become a regular continuing care patient in our practice?*
  • Do you want your mouth properly restored and pain free?*
  • We offer VELscope oral cancer screening for those interested ($75). Ask a team member if you would like it.

  • Page 5 · Medical history

  • Format: (000) 000-0000.
  • General health
  • Under a physician's care now?*
  • Any hospitalization in the past 5 years?*
  • Any serious illnesses/surgeries?*
  • Use tobacco in any form?*
  • Is pre-medication required before dental visits due to heart condition or artificial joint?*
  • Taking any prescription or daily OTC medications/drugs?*
  • Do you know of any reason why routine dental procedures might pose a risk to you, our staff or other patients?*
  • Is there anything important about your medical condition we have not asked?

  • Page 6 · Allergies and medications

  • All patients: Are you allergic to or have you ever had any reaction to the following? (Check all that apply)*
  • All patients: Are you currently taking any of the following? (Check all that apply)
  • Medication list
    Rows

  • PAGE 7 · Review of medical systems

  • Please check any of the items below that pertain to you.
  • General
  • Eyes
  • Ears, Nose, Mouth
  • Genito-Urinary
  • Allergic/Immunologic
  • Pulmonary
  • Gastrointestinal
  • Cardiovascular
  • Musculoskeletal
  • Integumentary
  • Neurologic
  • Psychological
  • Hematologic/Lymphatic
  • Endocrine
  • Substance/Chemical Use
  • Additional Questions
  • Neck
  • Women only
  • Due date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Financial Guidelines We are committed to providing you with the best care possible to achieve total health. In order to achieve these goals, we need your assistance and your understanding of our financial guidelines. INSURANCE We accept all major dental insurance payments, however we may not be an in-network provider for your plan. If we are not an in-network provider, review your plan details, as in many cases insurance reimbursement is very similar. • We will assist our patients in filing insurance claims through any benefit company that allows your choice of provider. As part of our legal agreements, the dental insurance plan administrators require that we offer no additional discounts and collect co-payment at the time of service. • We also offer our SmileSavers discounted health care services plan for our patients that do not have a dental benefit plan. • No estimate is a guarantee of payment. Please understand, you are responsible for all charges not paid by your insurance. Also, many insurance companies are excluding certain dental procedures or downgrading procedures to a lesser reimbursement level; in which case, you would be responsible for the difference. PAYMENTS Patient portion or patient co-payment is due at the time services are rendered – unless prior financial arrangements have been made. • Minors must be accompanied by a parent or legal guardian. If the parents are separated or divorced, the person accompanying the minor will be responsible for copayment at the time of service. • All major credit cards are accepted (Visa, MasterCard, Discover). • 3% discount for our uninsured patients who pay by cash/check. • Various financing options with CareCredit®. SHORT-NOTICE CANCELED/MISSED APPOINTMENTS • Please give a minimum 48 hour notice if you are unable to keep your reserved time. Unless an emergency occurs, we expect to run on time for your appointments and we appreciate the same courtesy from you. • Late, canceled or missed appointments may be subject to a fee of $75 for every 15 minutes of time reserved, or $50 for a hygiene appointment. If you are late, cancel or miss more than two appointments without notice in a 6-month period, you will be required to place a deposit in order to secure your appointment time.
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Acknowledgment of Privacy Practices My signature confirms that I have been informed of my rights to privacy regarding my protected personal and health information, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I understand the terms in which my personal health and identification information may be used. I have been informed of my dental provider's Notice of Privacy Practices containing a more complete description of the uses and disclosures of my protected health information. I have been given the right to review and receive a copy of such Notice of Privacy Practices. I understand that my dental provider has the right to change the Notice of Privacy Practices and that I may contact this office at the address above to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations and I understand that you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Relationship to patient*
  • Please list any dependent children under the age of 18 also covered by this acknowledgment
    Rows
  • In addition to the entities mentioned in the Notice of Privacy Practices, I authorize Synergy Dental Solutions to release my health information to the following individuals:
    Rows
  • I give permission for the following communications to be used by Dr. Angela Tenholder, DMD (check all that apply):*
  • I am granting permission for Angela Tenholder, DMD to leave a message with any person who may answer my phone or on my voicemail of the following numbers (check all that apply):*
  • I would like to give permission for the following person(s) to have access to personal information including but not limited to appointments, treatment, and billing of myself and any dependent children listed above:
    Rows
  • Patient Consent – Payment Authorization – Signature on File To the best of my knowledge, all of the preceding answers are correct. If I have any changes in my health status or if my medication changes, I shall inform the dentist and staff at the next appointment without fail. I hereby authorize payment directly to Dr. Angela Tenholder of the dental benefits otherwise payable to me. I hereby authorize Dr. Tenholder to release any information concerning my health or dental care, advice, treatment or supplies provided. This information is to be used in administering dental claims and/or discussing treatment options with other dental professionals. I understand and agree that (regardless of my insurance status) I am ultimately responsible for the balance on my account for any professional services rendered. By signing below, I acknowledge that I have read and understand the statements mentioned above.
  • Relationship to patient (if signing for a child)*
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Please also complete our Patient Photo Release.
  • Should be Empty: