Village Dental Patient Information

Date *

Month Day Year
Date
Email *
example@example.com
Patient Information
Patient Name *

First Name Last Name
Preferred Name/Nickname *
Please upload a facial photo of your child to attach to their chart *
Birth Date *

Month Day Year
Preferred Phone *

Area Code Phone Number
Alternate Phone

Area Code Phone Number
Social Security Number *
ex 111-11-1111
Residence *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
How long at this address?
Mailing Address

Street Address Line 2

City State

Zip Code
Take a photo of the Front of your Driver's License/ Identification Card *
Take a photo of the Back of your Driver's License/ Identification Card *
If patient is a minor give parent or guardian's name

First Name Last Name
Responsible Party/Partner/Spouse's Name (type Self if no additional Responsible Party) *

First Name Last Name
Responsible Party Phone Number

Area Code Phone Number
Who can we thank for referring you to our office? *

Insurance
Do You Have Insurance? *

Yes No

Policy Holder's Name *

First Name Last Name
Policy Holders Birthdate *

Month Day Year
Date
Take a photo of the Front of your Dental Insurance Card *
Take a photo of the Back of your Dental Insurance Card *
Policy Holders Social Security # *
Insurance Company *
Group # *
Insurance Company Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Area Code Phone Number
Policy Holder's Employer *
Do you have dual coverage?
Policy Holder's Name

First Name Last Name
Patient Birthdate *

Month Day Year
Date
Social Security #
Group #
Insurance Company Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Insurance Company Phone *

Area Code Phone Number
Policy Holder's Employer

Emergency Information
Name of nearest relative not living with you *

First Name Last Name
Phone Number *

Area Code Phone Number
Relationship *

Dental History
Check all that apply or you would like to discuss more with us *
Do you have a toothache? *
If yes please describe
Last dental exam? (estimate of date/year is okay) *
Last dental cleaning? (estimate of date/year is okay) *
Last dental x-rays? (estimate of date/year is okay) *
Previous Dentist Name *
Previous Dentist Phone Number

Area Code Phone Number
Have you been treated for Periodontal Disease? *
If yes please describe
Do you have Dental Implants? *
Do you wear an Occlusal Guard? *
Do you do at home Whitening or have you ever done Professional Whitening? *
Do you smoke? *
Do you use chewing tobacco? *
Medical History
Are you currently under the care of a physician? *
Physician's Name
Physician's Phone Number

Area Code Phone Number
If yes please describe what you are being treated for?
Most recent blood pressure?
Date of blood pressure reading?
Have you ever had a serious illness, hospitalization, surgery or other general health problems? *
If yes please explain?
List any drugs or medications now being taken. Give reasons. Type None if no medications are currently being taken. *
Have you taken any bone loss prevention drugs? *
If yes please list if it is Fosamax, Actonel, Boniva or other?
Are you sensitive or Allergic to: Please check all that apply or you would like to discuss more with us *
List Any Allergies or Drug Sensitivity. Type None if you have no known allergies: *
PLEASE ANSWER ALL QUESTIONS BY CHECKING BELOW All answers are confidential. Have you ever had or been treated for? *
Do you have any other disease, condition or problem not listed here that you think the doctor should know about?
If yes please specify?
Do you wish to talk with the doctor privately about anything?
Do you have a present complaint or concern that brought you into our office?

Patient Financial Resource

Below is a resource for you to better understand how we utilize insurance benefits, the payment options we offer and responsible party information. Please ask if you have any questions about the information below.

Participating Insurance Companies—We participate with certain insurance companies and accept their payment as payment-in-full, excluding any copayments or deductibles indicated in the contract you have with your insurance company. We will do all we can to maximize your insurance benefits in order to keep your out-of-pocket costs as minimal as possible. We advise all or our patients to read through their insurance contract so they can have the knowledge and understanding of the plan prior to treatment.

Non-Participating Insurance Companies - We accept most insurance plans even though we are not considered to be a participating provider. This means that you will be responsible for your copayments, deductibles and any difference between our fees and the fees your insurance company chooses to accept. We will treat your insurance the same as we treat an insurance plan we participate with, meaning, we will do all we can to maximize your insurance benefits in order to keep your out-of-pocket costs as minimal as possible.

No Insurance Coverage-We offer payment plans designed to fit your personal needs. We also accept Cash, Check, Visa, Mastercard, Discover, American Express and Care Credit. If you are without insurance, we do appreciate payment at the time of service. If a payment plan is needed, we will work with you to find the best option that fits into your budget.

Regarding Multiple Dental Plans-Secondary insurances are a great asset! We will submit claims to both your primary and secondary insurance plans to maximize the most of your insurance benefits. Sometimes, two insurance plans may not coordinate benefits due to a non-duplication clause or coordination of benefits clause. We will do all we can to find out this information for you prior to treatment, and we do advise our patients with dual insurance to also find this information out for themselves so they know what to expect from the insurance prior to treatment.

Responsible Party-Once our patients reach the age of eighteen (18), they are considered adults and therefore, responsible for their account. Patients seventeen (17) and younger are considered minors. A parent/legal guardian is responsible for treatment and financial decisions. In the event that parents are divorced, the parent that accompanies the minor to their appointment is responsible, regardless of the divorce decree.

Time of Payment-due to protocols set in place in response to the COVID Pandemic, all copayments are due two days prior to your appointment to limit your exposure in the office.

I hereby authorize Village Dental of Milford to release information acquired in the course of the examination and/or treatment for insurance and/or legal purposes. I understand the information presented to me and that I am financially responsible for the services I choose.
Date *

Month Day Year
Date
Signature (or Parent/Guardian if minor): *

Clear

Acknowledgment of Receipt of Statement of Privacy Practices

I acknowledge that I have recieved a copy of the Statement of Privacy Practices for the offices of Village Dental of Milford types of uses and disclosures of my protected health information that might occur in my treatment, payment or services, or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility.

Village Dental of Milford reserves the right to change the privacy practices currently described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed or otherwise transmitted to me.
ADDITIONAL DISCLOSURE AUTHORIZATION

In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my Protected Healthcare Information to the person(s) identified below. (I understand that the default answer is "NO". Without indicating "YES" in answer to the each individual question, personal protected (PHI) cannot be shared with anyone unless otherwise allowed by HIPAA rules.)
Spouse only: *
Any member of my immediate family: (Spouse, Children, Children's Spouses) *
Any member of my extended family: (Parents, Grandchildren) *
List below any additional person(s) (Girlfriend, Boyfriend, Primary Doctor, other)
Patient *

First Name Last Name
Patient /Guardian Signature *

Clear
Patient's personal representative if not self

First Name Last Name
Relationship to Patient
(mother, father, etc.)
Should be Empty:

Dental History

Medical History