New Patient Registration Form | Plaza Dental Group

8078 Douglas Avenue, Urbandale, IA 50322

(515) 276-7800
The benefits of a happy, healthy smile are immeasurable! Our goal is to help you reach and maintain maximum oral health. Please fill out this form completely. The better we communicate, the better we can care for you.

(The following confidential information is for our records only)
ABOUT YOU
Today's Date

MonthDayYear
Date
Name

PrefixFirst NameMiddle NameLast Name
How would you like our staff to address you?
Your Sex

MaleFemale
Birthdate

MonthDayYear
Date
Age
SS #
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital Status

SingleMarriedDivorcedSeparatedWidowed
Home #

Country CodeArea CodePhone Number
Cell #

Country CodeArea CodePhone Number
Work Phone

Country CodeArea CodePhone Number
Work Ext.
Email
example@example.com
Parent / Guardian Name (If under 18)
Best # for Parent / Guardian
Where & when are best times to reach you?
Whom may we thank for referring you?
Other family members seen by us
Previous Dentist
Present Dentist
Last Visit Date

MonthDayYear
Date
IN THE EVENT OF AN EMERGANCY, IS THERE SOMEONE WHO LIVES NEAR YOU THAT WE SHOULD CONTACT?
His / Her Name

First NameLast Name
Relation
Cell #
Please enter a valid phone number.
Work #
Please enter a valid phone number.
Home #
Please enter a valid phone number.
DENTAL INSURANCE
Primary Dental Insurance
Insurance Co. Name
Insurance Co Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Co. Phone #

Area CodePhone Number
Member #
Group# (Plan, Local or Policy#)
Insured's name
Relation
Insured's Birthdate

MonthDayYear
Date
Insured's SS #
Insured's Employer
Insured's Employer Addres

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Dental Insurance
Insurance Co. Name
Insurance Co Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone #

Area CodePhone Number
Group# (Plan, Local or Policy#)
Insured's name
Relation
Insured's Birthdate

MonthDayYear
Date
Insured's SS #
Insured's Employer
Insured's Employer Addres

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MEDICAL HISTORY

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

	Yes/No	If Yes, Please Explain
Are you under a physician's care now?
Have you ever been hospitalized or had a major operation?
Have you ever had a serious head or neck injury?
Are you taking any medications, pills or drugs?
Do you take, or have you taken, Phen-Fen or Redux?
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
Are you on a special diet?
Do you use tobacco?
Do you use controlled substances?
Have you ever had Botox/Dermafiller?
Do you suffer from Headaches or Migraines?
Do you grind or clench your teeth?

FOR WOMEN:

	Yes
Pregnant/Trying to get pregnant?
Nursing?
Taking oral contraceptives?

ARE YOU ALLERGIC TO ANY OF THE FOLLOWING:

	Aspirin	Penicillin	Codeine	Acrylic	Metal	Latex	Local Anesthetics	Sulfa Drugs	Other
Yes

If Other, please explain
Do you have, or have you had any of the following?

AIDS/HIV PositiveAlzheimer's DiseaseAnaphylaxisAnemiaAnginaAnxietyArthritis/GoutArtificial Heart ValveArtificial JointAsthmaBlood DiseaseBlood TransfusionBreathing ProblemBruise EasilyCancerChemotherapyChest PainsCold Sores/Fever BlistersCongenital Heart DisorderConvulsionsCortisone MedicineDepressionDiabetesDrug AddictionEasily WindedEmphysemaEpilepsy or SeizuresExcessive BleedingExcessive ThirstFainting Spells/DizzinessFrequent CoughFrequent DiarrheaFrequent HeadachesGenital HerpesGlaucomaHay FeverHeart Attack/FailureHeart MurmurHeart Pace MakerHeart Trouble/DiseaseHemophiliaHepatitis AHepatitis B or CHerpesHigh Blood PressureHigh CholesterolHives or RashHypoglycemiaIrregular HeartbeatKidney ProblemsLeukemiaLiver DiseaseLow Blood PressureLung DiseaseMitral Valve ProlapseOsteoporosisPain in Jaw JointsParathyroid DiseasePsychiatric CareRadiation TreatmentsRecent Weight LossRenal DialysisRheumatic FeverRheumatismScarlet FeverShinglesSickle Cell DiseaseSinus TroubleSleep ApneaSpina BifidaStomach/Intestinal DiseaseStrokeSwelling of LimbsThyroid DiseaseTonsillitisTuberculosisTumors or GrowthsUlcersVenereal DiseaseYellow Jaundice
NO TO ALL THE ABOVE
Have you ever had any serious illness not listed above?
If Yes, please explain
Comments
PATIENT CONSENT

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.
Name

First NameLast Name
Signature

Clear
Date

MonthDayYear
Date
Thank you for filling our this form completely. It will enable us to help you more effectively. If you have any questions at any time, please ask us. We are happy to help. Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.
Urbandale Smiles complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex.
APPOINTMENT CONDITIONS
Our part in our relationship is to help you keep your teeth, your part in our relationship is to make sure to keep your appointments. We are asking for your assistance and understanding of our cancellation conditions.

We require a 24 hour notice if you are needing to change or cancel any scheduled appointment. If you are not able to give us a 24 hour notice a fee will occur from your missed appointment.

If your appointment is with a doctor, you will forfeit 10% of the scheduled treatment. Upon rescheduling your appointment, you will owe the 10% that was forfeited upon missing the previous appointment.

If your appointment is with your hygienist, a fee of $50 will be charged to the card on file.

We never want you to rush when brushing your teeth and we do not want to rush with your appointment. If you are 15 minutes late for your appointment you may be asked to reschedule or we may be required to shorten the length of the planned treatment.

We are happy to assist in rescheduling your appointment by calling the office at 515-276-7800

I acknowledge I have read the above terms and conditions.
Name

First NameLast Name
Patient Signature (Parent or Guardian of Minor)

Clear
Date

MonthDayYear
HIPAA COMPLIANCE PATIENT CONSENT FORM
Our notice of privacy practlces provides information about how we use or disclose protected health information.

The notice contains a patient's right section describing your rights under the law. You ascertain that by signature that you have reviewed our notice of privacy practices.

The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare options. We are not required to agree with the restriction, but If we do, we shall honor this agreement. The HIPAA law allows for the use of the information for treatment, payment, or healthcare options.

By signing this form, I understand that:

•    Protected health information may be disclosed or used for treatment, payment, or healthcare operations.

•   The practice reserves the right to change the privacy policy as allowed by law.

•   The patient has the right to restrict the use of the information but the practice does not have to agree to those restrictions.

•   The patient has the right to revoke the consent in writing at any time and all full disclosures will then cease.

•   The practice may condition receipt of treatment upon execution of this consent.

If you would like us to dlscuss your treatment with any member of your family please list below:
Name

First NameLast Name
Relationship
Name

First NameLast Name
Relationship
I attest that the above information is correct.
If you do not want to share your information with any other party please leave the above information blank and sign below.
Patient Name

First NameLast Name
Patient / Guardian Signature

Clear
Date

MonthDayYear
Date
FINANCIAL GUIDELINE
Thank you for choosing our office as your dental health care provider. At Urbandale Smiles we are committed to providing you with the best possible dental care, so that you may fully attain optimum oral health. Please understand that payment of your bill is considered part of your treatment. In order to achieve these goals, we need your assistance and understanding of our payment policy.

Payment is due upon scheduling treatment. We accept payments by cash, check or credit card (MasterCard, Visa, American Express and Discover). We also accept CareCredit, Outside financing is available upon request and approval (Proceed and iCredit Works).

If you have dental insurance, we will help you receive your maximum allowable benefits. We will gladly discuss your proposed treatment and answer any questions relating to your insurance. However, please realize:

Your insurance is a contract between you, your employer and the insurance company. We are not a party to that contract. When our office verifies your insurance and we provide an estimate of benefits for services, your insurance company has a disclaimer that there is no guarantee of benefits. Insurance companies have the liberty to change your benefit structure at any given time without notifying our office. Having dental insurance does not guarantee payment.

We must emphasize that as a dental care provider, our relationship is you, our patient and your family and not with your insurance company. While the filing of the insurance claims is a courtesy that we extend to our patients, all charges are your responsibility from the date the services are rendered.

We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in the management of your account. If you have any questions about the above information, please do not hesitate to ask us. We are here to help you!

I acknowledge I have read, understand and agree to the above terms and conditions. If I have insurance, I authorize my insurance company to pay my dental benefits to my dental office.
Patient Name

First NameLast Name
Signature

Clear
SLEEP QUESTIONNAIRE - 18 and older
Name

First NameLast Name
Date

MonthDayYear
Date
Have you ever had a sleep study?
When?
Do you use a CPAP machine?

YesNo
Do you use it regularly?

YesNo
Rate your overall energy level

1

2

3

4

5

6

7

8

9

10

1 is Low, 10 is Excellent
Rate your Sleep Quality

1

2

3

4

5

6

7

8

9

10

1 is Low, 10 is Excellent
Mark all that apply:

Difficulty falling asleepDifficulty maintaining sleepWould you consider your life stressfulFrequent snoringWaking up gaspingChoking while sleepingFeeling unrefreshed in the morningExcessive daytime sleepinessMigraines or headachesNeck or facial painMemory ProblemsImpotence (Erectile Dysfunction)Nasal Problems, difficulty breathing through your noseIrritability or mood swingsHigh blood pressureClench/grind your teeth
If you have marked any of the above as YES please say here how often:
CURRENT DENTAL STATUS SURVERY

On a scale of 1-10, with 10 being the highest please mark your rating:
How important is your dental health to you?

1

2

3

4

5

6

7

8

9

10

1 is Not Important, 10 is Extremely Important
Where would you rate your current dental health?

1

2

3

4

5

6

7

8

9

10

1 is Bad, 10 is Excellent
How confident are you in your smile?

1

2

3

4

5

6

7

8

9

10

1 is , 10 is
What is the most important thing to you about your future smile dental health?
What is the most important thing to you about your dental visit today?
If you could change your smile, you would:

Make them brighterHave a smile makeoverRepair chipped teethReplace black metal fillings with natural, tooth-colored fillingsMake them straighterReplace old crowns that do not muchReplace missing teethClose spacesOther
Which of the following oral conditions have you experienced since your last dental visit? Please check any that apply:

Sensitivity (hot, cold, sweet)TMJ (jaw pain) (clicking or popping)Teeth or fillings breakingBleeding, swollen or irritated gumsTooth pain or discomfortLoose or shifting teethCracked or chipped teethOther
How many times a day do you brush?
How many times a day / week do you floss?
Do you use a waterpik?
Have you had your teeth straightened in the past? Yes (when?)
If you currently have a partial or denture would you be interested in learning about how to make them a permanent and more comfortable solution?

YesNo
Do you have any fears of dental visits?

YesNo
If Yes, please explain
Do you have an upcoming event where you are wanting to show your new smile to the world? Yes (when/what)
Is there anything else you would like us to know?
Are you interested in any of the following? Please check which ones you are interested in.

Amalgam RemovalOzoneOzonideProlozoneMuscle TestingBiocompatibility TestingAirway ExpansionMyofunctional Therapy
If you had three wishes to change your oral and whole body health, what would they be?
1.
2.
3.
Describe your typical breakfast:
Describe your typical lunch:
Describe your typical dinner:
How many servings per day do you get of fresh / frozen fruits and vegetables:
How many servings per week are you getting of fish and other healthy omega fatty acids:
How many cups of water do you drink per day:
Do you drink carbonated beverages?

YesNo
How often:
Do you find yourself eating on the go or sitting down and eating?
Digestion: Please check all that apply:

BloatingCrampingRefluxIndigestion
How are your bowel movements?
List ALL Natural / Non-Prescription Supplements you are currently taking: Supplement / Dose / Frequency / Purpose
What is your current height?
What is your current weight?
Please check any of the following you have EVER had or have at present:
MusculoSkeletal

Degenerative Disc DiseaseOsteoarthritisSpinal FusionScoliosisChronic Muscle CrampsEhlers Danlos SyndromeJoint HypermobilityHerniated Discs
Immune Mediation Issues

MTHFR Genetic VariationChronic Fatigue SyndromeSjogren's SyndromeOrgan TransplantFibromyalgiaLupusMold Induced DiseaseLyme Disease
Gastrointestinal

Dietary SensitivitiesFood Allergies/IntoleranceColon PolypsCeliac DiseaseCrohn's DiseaseChronic Intestinal BloatingAcid RefluxIrritable Bowel SyndromeNutritional DeficienciesGastric UlcersGastric BypassGut Dysbiosis/SIBO/SIFOChronic Candida
Endocrine

Insulin ResistancePolycystic Ovary DiseaseAbdominal ObesityFrequent Thirst or UrinationMetabolic SyndromeAdrenal FatigueHyperthyroidismHypothyroidismHashimoto's Thyroiditis
Neurologic

Panic AttacksInsomniaRestless Leg SyndromePost Traumatic Stress DisorderSchizophreniaBipolar
Peripheral / Vascular

Peripheral Vascular DiseasePulmonary EmbolismDeep Vein ThrombosisRaynaud's DiseaseThoracic Aortic AneurysmVaricose VeinsAnkles/Leg Swell
Cardiac

Atrial FibrillationOpen Heart SurgeryMitral Valve StenosisHeart BypassAngioplasty/StentEar Lobe CreasesPacemakerGestational Preeclampsia
Mouth / Throat

Periodontal DiseaseTongue TieLip TieBurning Mouth SyndromeBad BreathDenturesDental Implant
Eyes

Retinal Vascular DiseaseCataractsGlasses / Contacts
Skin

PsoriasisLichen PlanusPemphigusEczema
Ears

Tubes in EarsChronic Ear InfectionsSevere Hearing ImpairmentHearing Aids
Hematologic

Von Willebrand's DiseaseLeiden Factor V DeficiencyThrombocytopenia
Hepatic

Cirrhosis of LiverElevated CholesterolGallbladder Issues
Respiratory

Exercise Induced AsthmaPersistent CoughChronic BronchitisReactive Airway Disease
Nose / Sinus / Allergy

Chronic Nasal CongestionDeviated SeptumChronic Sinus CongestionSeasonal AllergiesRecurrent Unexplained Hives
Genitourinary

Chronic UTlsBladder RefluxLow TestosteroneLow Progesterone
Name and phone number of current physician:
Do you see a medical specialist, functional medicine doctor, alternative medicine practitioner or naturopath?

YesNo
What is their speciality? Please share name:
What do you normally take to resolve aches and pains?
What are your current Vitamin D levels?
Approx last date of the report?
Past history of orthodontics?

YesNo
ON a scale of 1 to 10, how do you feel about visits to the dental office (1 - calm, not an issue / 10 - very anxious)
If you have to make a decision, do you prefer:

A lot of details, the more the better!The bottom line, don't bother with the details.Small pieces of information at a time so I don't get overwhelmed.
Should be Empty:

8078 Douglas Avenue, Urbandale, IA 50322

The benefits of a happy, healthy smile are immeasurable! Our goal is to help you reach and maintain maximum oral health. Please fill out this form completely. The better we communicate, the better we can care for you.

ABOUT YOU

IN THE EVENT OF AN EMERGANCY, IS THERE SOMEONE WHO LIVES NEAR YOU THAT WE SHOULD CONTACT?

DENTAL INSURANCE

Primary Dental Insurance

Secondary Dental Insurance

MEDICAL HISTORY

PATIENT CONSENT

APPOINTMENT CONDITIONS

HIPAA COMPLIANCE PATIENT CONSENT FORM

FINANCIAL GUIDELINE

SLEEP QUESTIONNAIRE - 18 and older

CURRENT DENTAL STATUS SURVERY