Adlong Dental New Patient Form

Patient Informaton

David Ouellette DDS
Name*

First NameMiddle NameLast Name
Gender*

MaleFemaleOther
Is anyone in your family a current patient?*

YesNo
What's their name?
SSN#*
Driver License #
Birth Date:*
Phone (Home):*

Area CodePhone Number
Phone (Cell):

Area CodePhone Number
Phone (Work):

Area CodePhone Number
E-mail*
Preferred Method of Contact:

Text MessageE-MailPhone Call
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Referral Information
Whom may we thank for referring you to our practice?

PatientRelativeFriendDental OfficeYellow PagesInternetSchoolWork
Name of person or office referring you to our practice:
Health Information
Date of Last Dental Visit

MonthDayYear
Reason for today's visit
Have you ever had any of the following? Please check those that apply*

AIDS/HIV+AnemiaArthritisArtificial JointsAsthmaBlood DiseaseCancerDiabetesDizzinessEpilepsyExcessive BleedingFaintingGlaucomaGrowthsHay FeverHead InjuriesHeart DiseaseHeart MurmurHepatitisHigh Blood PressureJaundiceKidney DiseaseLiver DiseaseMental DisordersMirtral Valve ProlapseNervous DisordersPacemakerPregnantRadiation TreatmentRespiratory ProblemsRheumatic FeverRheumatismSinus ProblemsStomach ProblemsStrokeTuberculosisTumorsUlcersVenereal DiseaseNone of these
Do you have any allergies?

YesNo
Please list your allergies here:
Are you currently on any medications? *

YesNo
Please list your current mediations:
Have you ever had any complications following dental treatment?*

YesNo
If yes, please describe your dental complications.
Have you been admitted to the hospital or needed emergency care during the past two years?*

YesNo
If yes, please descibe your hospital stay.
Are you now under the care of a physician?*

YesNo
Is yes, please describe your current care.
Name of physician:
Phone Number:
Do you have any health problems that need further clarification?*

YesNo
Please explain.
Are you interested in any of the following:

InvisalignOrthodonticsImplantsCrownPartialDenturesTeeth Whitening
Are you happy with your smile?*

YesNo
Please tell us what about your smile you would like to approve upon
Employment Information
Employer Name
Occupation
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Insurance Information
Does the patient have dental insurance?*

YesNo
Would you be interested in financing options?

YesNo
Name of Insurance Company
Name of Insured

First NameMiddle NameLast Name
Insured's Date of Birth

MonthDayYear
ID #
Group #
If you are on a smartphone or tablet and can take a photo of your insurance card, please do so now. If not please ignore this box.
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insured's Employer Name
Patient's Relationship to insured:

SelfSpouseChildOther
Parent or Guardian Information
Please Select

FatherStep-FatherGuardian
Name

First NameLast Name
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
SSN#
DL#
Insured's Employer Name
Patient's relationship to insured

SelfSpouseChildOther
Please Select

MotherStep-MotherGuardian
Name

First NameLast Name
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
SSN#
DL#
Insured's Employer Name
Patient's relationship to insured

SelfSpouseChildOther
As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends on reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment.

All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed.

Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patients insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.

I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination.

In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, or within five (5) days of billing if credit shall be extended. I further agree that a reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suited be instituted hereunder.

I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form.

To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail.

I have read the above conditions of treatment and payment and agree to their content.
Signature of patient, parent or guardian (You may sign with your finger on your touchscreen device, or using a mouse) By doing so you agree that this is a legally binding signature in accordance with the office late fee, as well as current office procedures as outlined in the above text.*
Date*

MonthDayYear
Relationship to Patient
David Ouellette DDS PA HIPAA Consent Form
I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out the following:
- Treatment (including direct or indirect by other healthcare provides involved in my treatment)
- Obtaining payment from third party payers (e.g. my insurance company)
- The day-today healthcare operations of your practice.
I have also been informed of, and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of the notice from time to time and that I may contact you at any time to obtain the most recent copy of this notice.

I understand that I have the right to request restrictions on how my protected health information is used and discussed to carry out treatment, payment and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.

I understand that I may revoke this consent, in writing, at anytime. However, any use or disclosure that occurred prior to the date I revoked this consent is not affected.

David Ouellette DDS PA Dental Office Policies

Office Financial Policy

Payment is due the day of service. As a service to our patients we will file your dental insurance for you. As long as your insurance can be verified, you will only be responsible for your estimated percentage of treatment on that day of service. We can only give and estimate of what insurance will pay, any remaining balance is your responsibility.

48 Hours Notice Policy

It is very important that we receive notice of a change in plans at least 48 hours in advance. This gives us the chance to schedule another patient in your place. If we do not have sufficient notice regarding a schedule change, we will be unable to care for another patient in need of our services.

David Ouellette DDS PA is sure that you understand why we must have policies along these lines. It is our policy to charge a $30.00 missed appointment fee to any patient that cancels their appointment the day of the appointment.

I understand that by signing this agreement I am expected to adhere to the policies set forth within this notice.
Name*

First NameMiddle NameLast Name
Date*

MonthDayYear
Relationship to patient
Signature of patient, parent or guardian (You may sign with your finger on your touchscreen device, or using a mouse) By doing so you agree that this is a legally binding signature in accordance with David Ouellette DDS PA HIPAA Consent form and all information held therein.*
Should be Empty:

Patient Informaton

Referral Information

Health Information

Employment Information

Insurance Information

Parent or Guardian Information

David Ouellette DDS PA HIPAA Consent Form