New Patient Forms - Kalamazoo

CONFIDENTIAL INFORMATION QUESTIONNAIRE
PATIENT'S LEGAL NAME*

First NameMiddle InitialLast Name
DATE OF BIRTH*
SEX*
PREFER TO BE CALLED
SSN*
HOME PHONE #*

Area CodePhone Number
CELL PHONE #

Area CodePhone Number
PATIENT'S ADDRESS*
EMAIL
Marital Status

SingleMarriedWidowedDivorcedUnder age 18
PATIENT'S / GUARDIAN'S EMPLOYER
OCCUPATION
WORK ADDRESS
WORK PHONE #

Area CodePhone Number
SPOUSE'S NAME

First NameLast Name
SPOUSE'S EMPLOYER
OCCUPATION
SPOUSE'S WORK ADDRESS
WORK PHONE #

Area CodePhone Number
OTHER FAMILY MEMBERS THAT ARE PATIENTS HERE
WHO CAN WE THANK FOR REFERRING YOU TO OUR OFFICE?
EMERGENCY CONTACT INFORMATION

PERSON WE MAY CONTACT IN CASE OF AN EMERGENCY (OTHER THAN YOUR FAMILY HOME)
Name*

First NameLast Name
RELATIONSHIP*
HOME PHONE #*

Area CodePhone Number
WORK PHONE #

Area CodePhone Number
CELL PHONE #

Area CodePhone Number
REQUEST FOR CONFIDENTIAL COMMUNICATION

AS MY DENTAL CARE PROVIDER, YOU MAY DO THE FOLLOWING WITH MY PERMISSION:
Contact me at home*

YESNO
Contact me via cell phone*

YESNO
Contact me at work*

YESNO
Contact me via email*

YESNO
Leave messages on my home voicemail / answering machine*

YESNO
Leave messages on my cell phone voicemail*

YESNO
Leave messages on my work voicemail / answering machine*

YESNO
PHARMACY
PHARMACY NAME
PHONE NUMBER

Area CodePhone Number
INSURANCE AND FINANCIAL INFORMATION
INSURANCE COVERAGE*

YESNO
INSURANCE COMPANY NAME*
INSURANCE ADDRESS
INSURANCE PHONE

Area CodePhone Number
SUBSCRIBER'S NAME*
SUBSCRIBER'S BIRTHDAY*
PATIENT'S RELATIONSHIP TO SUBSCRIBER*

SELFSPOUSEDEPENDENT
GROUP/PROGRAM NUMBER*
SUBSCRIBER ID*
EMPLOYER (IF DIFFERENT FROM ABOVE)
EMPLOYER'S ADDRESS
SECONDARY COVERAGE

YESNO
INSURANCE COMPANY NAME
INSURANCE ADDRESS
INSURANCE PHONE

Area CodePhone Number
SUBSCRIBER'S NAME
SUBSCRIBER'S BIRTHDAY
PATIENT'S RELATIONSHIP TO SUBSCRIBER

SELFSPOUSEDEPENDENT
GROUP/PROGRAM NUMBER
SUBSCRIBER ID
EMPLOYER (IF DIFFERENT FROM ABOVE)
EMPLOYER'S ADDRESS
RELEASE INFORMATION

YOU MAY DISCUSS MY HEALTHCARE WITH
Health Care Providers*

YESNO
Insurance Companies*

YESNO
Others (Please List):
CONFIRMATIONS

DO YOU PREFER A CONFIRMATION CALL?
No, it is unnecessaryYes, it is a helpful reminder
ASSIGNMENT AND RELEASE
I hereby authorize my insurance benefits to be paid directly to the dentists. I am financially responsible for any balances due and authorize the dentists to release any information for this claim. I authorize that my records can be used by the doctor if he so determines. In consideration of the services rendered to me by this dental office, I am obligated to pay said office in accordance with its credit terms and policy.

I consent to the making of videotapes, photographs, and x-rays before, during and after treatment, and to use of the same by the doctor in scientific papers or demonstrations.

I certify that I have read or had read to me the contents of this form and do realize the risks and limitations involved.
SIGNATURE - PATIENT/GUARDIAN - Please draw your signature using your finger if on a mobile device or mouse cursor if on a computer. Your full signature must be included for your form to be valid.*

Clear
Date

MonthDayYear
Date
WITNESS SIGNATURE

Clear
Date

MonthDayYear
Date
MEDICAL HISTORY
Patient Name:*

First NameLast Name
Birth Date:*
Today's Date:

MonthDayYear
Date
What is your estimate of your overall general health?*

ExcellentGoodFairPoor
Have you ever been hospitalized for an illness or injury?*

YesNo
If yes, please explain:
DO YOU HAVE OR HAVE YOU EVER HAD an allergic reaction to any of the following (select all that apply):

aspirin, ibuprofen, acetaminophen, codeinepenicillinerythromycintetracyclinesulfalocal anestheticfluoridechlorhexidine (CHX)metals (nickel, gold, silver, etc)latexnutsfruitOther
DO YOU HAVE OR HAVE YOU EVER HAD (select all that apply):

heart problems or cardiac stent within the last six monthshistory of infective endocarditisartificial heart valve, repaired heart defect (PFO)pacemaker or implantable defibrillatororthopedic implant (joint replacement)rheumatic or scarlet feverhigh or low blood pressurea stroke (taking blood thinners)anemia or other blood disorderprolonged bleeding due to a slight cut (INR > 3.5)pneumonia, emphysema, shortness of breath, sarcoidosischronic ear infections, tuberculosisasthmabreathing or sleep problems (i.e. sleep apnea, snoring, sinus)kidney diseaseliver diseasejaundicethyroid, parathyroid disease, or calcium deficiencyhormone deficiencyhigh cholesterol or taking statin drugsdiabetesstomach or duodenal ulcerdigestive or eating disorders (celiac disease, gastric reflux)osteoporosis/osteopenia (taking bisphosphonates)arthritisautoimmune disease (rheumatoid arthritis, lupus, scleroderma)glaucomacontact lenseshead or neck injuriesepilepsy/convulsions (seizures)neurologic disorders (ADD/ADHD, prion disease)viral infections and cold soresany lumps or swelling in the mouthhives, skin rash, hay feverSTI/STD/HPVhepatitisHIV/AIDStumor, abnormal growthradiation therapychemotherapy, immunosuppressive medicationemotional difficultiespsychiatric treatmentantidepressant medicationalcohol/recreational drug use
ARE YOU (select all that apply):

presently being treated for any other illnessesaware of a change in your health in the last 24 hourstaking medication for weight managementtaking dietary supplementsoften exhausted or fatigueda smoker, smoked previously or use smokeless tobaccoconsidered a touchy/sensitive personoften unhappy or depressedtaking birth control pillscurrently pregnantdiagnosed with a prostate disorder
Did you answer yes to any of the questions above?*

YesNo
If yes, please explain:
Describe any past or current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment (i.e. Botox/Collagen injections):
Please list all medications, supplements and/or vitamins taken within the last two years and provide purpose in the comment:
Signature of Patient, Parent or Guardian: Please draw your signature using your finger if on a mobile device or mouse cursor if on a computer. Your full signature must be included for your form to be valid.*

Clear
Date

MonthDayYear
Date
DENTAL HISTORY
Name:*

First NameLast Name
Nickname:
Age:*
How would you rate the condition of your mouth?*

ExcellentGoodFairPoor
Referred by:
Previous dentist:*
How long have you been a patient?*
Months/Years
Date of most recent dental exam

MonthDayYear
Date
Date of most recent x-rays

MonthDayYear
Date
Date of most recent treatment (other than a cleaning)

MonthDayYear
Date
I routinely see my dentist every:*

3 months4 months6 months12 monthsNot routinely
WHAT IS YOUR IMMEDIATE CONCERN?
PLEASE ANSWER YES OR NO TO THE FOLLOWING:
PERSONAL HISTORY
1. Are you fearful of dental treatment?*

YESNO
How fearful, on a scale of 1 (least) to 10 (most)?
2. Have you had an unfavorable dental experience?*

YESNO
3. Have you ever had complications from past dental treatment?*

YESNO
4. Have you ever had trouble getting numb or had any reactions to local anesthetic?*

YESNO
5. Did you ever have braces, orthodontic treatment or had your bite adjusted?*

YESNO
6. Have you had any teeth removed or missing teeth that never developed?*

YESNO
GUM AND BONE
7. Do your gums bleed or are they painful when brushing or flossing?*

YESNO
8. Have you ever been treated for gum disease or been told you have lost bone around your teeth?*

YESNO
9. Have you ever noticed an unpleasant taste or odor in your mouth?*

YESNO
10. Is there anyone with a history of periodontal disease in your family?*

YESNO
11. Have you ever experienced gum recession?*

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

YESNO
13. Have you experienced a burning or painful sensation in your mouth not related to your teeth?*

YESNO
TOOTH STRUCTURE
14. Have you had any cavities within in the past 3 years?*

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

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

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

YESNO
18. Do you have grooves or notches on your teeth near the gum line?*

YESNO
19. Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?*

YESNO
20. Do you frequently get food caught between any teeth?*

YESNO
BITE AND JAW JOINT
21. Do you have any problems with your jaw joint? (Pain, sounds, limited opening, locking, popping)*

YESNO
22. Do you feel like your lower jaw is being pushed back when you bite your teeth together?*

YESNO
23. Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?*

YESNO
24. Have your teeth changed in the last 5 years, become shorter, thinner or worn?*

YESNO
25. Are your teeth becoming more crooked, crowded or overlapped?*

YESNO
26. Are your teeth developing spaces or becoming more loose?*

YESNO
27. Do you have to make more than one bite, squeeze, or shift your jaw to make your teeth fit together?*

YESNO
28. Do you place your tongue between your teeth or close your teeth against your tongue?*

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

YESNO
30. Do you clench your teeth in the daytime or make them sore?*

YESNO
31. Do you have any problems with sleep (i.e. restlessness), wake up with a headache or an awareness of your teeth?*

YESNO
32. Do you wear or have you ever worn a bite appliance?*

YESNO
SMILE CHARACTERISTICS
33. Is there anything about the appearance of your teeth that you would like to change?*

YESNO
34. Have you ever whitened (bleached) your teeth?*

YESNO
35. Have you ever felt uncomfortable or self conscious about the appearance of your teeth?*

YESNO
36. Have you been disappointed with the appearance of previous dental work?*

YESNO
Patient's Signature - Please draw your signature using your finger if on a mobile device or mouse cursor if on a computer. Your full signature must be included for your form to be valid.*

Clear
Date

MonthDayYear
Date
Financial Policy
This is an agreement between Drake Dental, as creditor and the Patient/Debtor named on this form. By executing this agreement, you are agreeing to pay for all services that are received. Payment in full for your portion is expected at the time of scheduling. All insurance co-payments and deductibles are expected at the time of scheduling.

Payment Options
1. We gladly accept cash, Visa/Mastercard, HSA card or check (for existing patients with established payment history). There is a $35 fee for any checks returned from the bank.
2. If you are in need of extended financing, we are pleased to offer a third party financing option through Care Credit for those who qualify.
3. All estimated patient copays are due when reserving your appointment time.
Insurance: Your dental benefits (insurance) are based upon a contract made between your employer and an insurance company. We are not a party to this contract in most cases. As a courtesy, we bill your insurance company. We currently accept all private care insurance plans. This means that we work with literally hundreds of companies. Although we can maintain computerized histories of payment by a given company, they do change; therefore it is impossible to give you a guaranteed quote at the time of service. We estimate your portion based on the most up-to-date information we have, but it is ONLY AN ESTIMATE. If you would like a more accurate insurance benefit estimate, we encourage you to contact your insurance carrier. If your insurance does not pay within 90 days, Drake Dental reserves the right to request payment in full for services from you and let you collect the insurance funds that are due to you. This is rare, but it is important that you recognize that the insurance benefit you have is a legal contract between YOU and your insurance company. Ultimately, you are responsible for all charges incurred in our office.

Verification: We make every attempt to verify your insurance benefits prior to your appointment. It is imperative that you contact us with any insurance changes at least 2 business days prior to your appointment. If we do not have your current insurance information at LEAST 2 BUSINESS DAYS prior to your scheduled appointment, we kindly ask that you pay for your appointment in full. We will then provide you with the information to submit your claim for reimbursement.

Finance Charge: A finance charge will be imposed on balances not paid within 30 days of the time the item was added to the account. The FINANCE CHARGE will be computed at the rate of one and one half percent (1.5%) per month or an ANNUAL PERCENTAGE rate of eighteen percent (18%). The finance charge on your account is computed by applying the periodic rate (1%) to the overdue balance of your account. The “overdue balance” of your account is calculated by taking the balance owed thirty (30) days ago, and then subtracting any payments or credits applied to the account during that time. The minimum finance charge is $0.50.

Credit History: We have the option to report your overdue account status to any credit reporting agency such as a credit bureau.

Broken Appointment Fee: Patients who do not show up on time for an appointment or cancel with less than 2 business days’ notice will be charged a fee. This fee must be paid before a new appointment is scheduled. Patients with three missed appointments will be asked to transfer their records to another dental office.
Patient's Name:*
Responsible Party (if not the patient):
Patient's Signature - Please draw your signature using your finger if on a mobile device or mouse cursor if on a computer. Your full signature must be included for your form to be valid.*

Clear
Date

MonthDayYear
Date
465 S. Drake Rd., Kalamazoo, MI 49009

(269) 344-7222
Acknowledgement of receipt of Notice of Privacy Practices
*You may refuse to sign the acknowledgement*
Name:*
Signature: Please draw your signature using your finger if on a mobile device or mouse cursor if on a computer. Your full signature must be included for your form to be valid.

Clear
Date:

MonthDayYear
Date
For Office Use Only

We attemped to obtain acknowledgement of receipt of our Notice of Privacy Practice, but acknowledgement could not be obtained because:

[ ] Individual refused to sign

[ ] Communication barriers prohibited obtaining the acknowledgement

[ ] An emergency situation prevented us from obtaining acknowledgement

[ ] Other (Please specify below)
Radiograph Policy
X-Rays provide one of the best diagnostic tools in dentistry. They enable the dentist and hygienist to see inside the tissue of the teeth, gums and bones of the jaw. We assure you that we are conservative in our use of x-rays, but without them, decay and other diseases of the teeth and mouth often cannot be diagnosed until serious damage has been done.

We never take unnecessary x-rays. The American Dental Association recommends that radiographs be taken at regular intervals to check for signs of decay or disease, such as bone loss or oral cancer, and for diagnostic purposes when indicated. In our office:
- Bitewings are taken 1x / calendar year
- Panoramics are taken 1x / 3 calendar years
- PAs are taken as needed or as prescribed by the doctor
We do NOT accept radiographs from other offices as software may vary and images do not transfer well. Exceptions can be made for orthodontics or patients with recent oral surgery on a case by case basis (this is determined by the DDS on staff). All new patient appointments require new imaging to create a patient baseline.

Some dental insurance plans have limits on their coverage of radiographs. If you have dental insurance, please check your policy’s coverage. You may be responsible for the fees involved, as insurance may not cover at 100%. Please be prepared at every visit for any potential co-pays.

REFUSAL OF X-RAYS leaves our practice at a liability. Disease can be easily missed without imaging. Doctors cannot properly diagnose with an incomplete exam. Patients have the right to refuse imaging, just as dentists have the right to refuse treatment. Failure to comply with regular x-ray intervals could lead to dismissal as a patient, or cancellation of upcoming appointments.

By signing this form I agree to and understand all radiograph policies and procedures in place by Drake Dental. I understand that failure to comply with the imaging policy could lead to dismissal as a patient or rescheduling of my appointments. I understand that my insurance may not cover all imaging at the standard intervals and I will be prepared for any copays.
Name:*
Signature: Please draw your signature using your finger if on a mobile device or mouse cursor if on a computer. Your full signature must be included for your form to be valid.*

Clear
Date:

MonthDayYear
Date
Which of our offices should receive your forms?*

Portage officeKalamazoo office
Should be Empty:

CONFIDENTIAL INFORMATION QUESTIONNAIRE

EMERGENCY CONTACT INFORMATION

REQUEST FOR CONFIDENTIAL COMMUNICATION

PHARMACY

INSURANCE AND FINANCIAL INFORMATION

RELEASE INFORMATION

CONFIRMATIONS

ASSIGNMENT AND RELEASE