New Patient Paperwork | Specialized Periodontal Implant Team

New patient paperwork. Please complete the form below and submit it. It goes securely to the practice, formatted on our standard forms so we can print it for your chart.

Personal Information

Today’s date * Name * Preferred name Date of birth * SSN Marital status Address * City * State * Zip * Home phone Cell phone Work phone Email Employer Occupation Referred by General dentist

Our office sends appointment reminders by text & email.

Dental Insurance

Insurance company Subscriber name Subscriber SSN or ID# Subscriber employer Subscriber date of birth Group#

Secondary Dental Insurance

Insurance company Subscriber name Subscriber SSN or ID# Subscriber employer Subscriber date of birth Group#

Medical History

Height * Weight * Last medical checkup

Are you under a physician’s care now? Yes No

If yes, please explain

Have you been hospitalized or had a major operation? Yes No

If yes, please explain

Have you ever had a serious head or neck injury? Yes No

If yes, please explain

Do you consider your medical health to be good? Yes No

Are you on a special diet? Yes No

Do you use tobacco? Yes No

Do you drink alcohol regularly? Yes No

Do you use controlled substances? Yes No

Do you PRE-MED for any reason? Yes No

Any family history of the following? Heart Disease Cancer Diabetes Gum Disease

Pregnancy 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 Other

Have you ever had any serious illness not listed above? Yes No

If yes, please explain

Dental History

General dentist Referring doctor

Have you been experiencing pain from your mouth lately? Yes No

Are you experiencing pain from your mouth at this time? Yes No

Have you had swollen areas of the gum lately? Yes No

When did you last have your teeth cleaned? How often in the last 5 years?

Do your gums bleed? Yes No

Do you have dry mouth? Yes No

Do your gums bleed when you brush? Yes No

Are your teeth sensitive to hot, cold or sweets? Yes No

If sensitive, which teeth? How often do you brush your teeth? What type of toothbrush do you use? How often do you floss your teeth?

Do you smoke? Yes No

If yes, how much? What?

Have you ever had periodontal (gum) treatments? Yes No

When? Doctor’s name Treatment performed

General Questions

Do you wish to talk privately about any problem? Yes No

Do you currently take any medications? Yes No

If yes, please list all medications and why you are taking them

Certification

To the best of my knowledge, the questions on these forms have been accurately answered. I understand that providing incorrect medical history information can be dangerous to the patient’s health. It is my responsibility to inform the dental office of any changes in the patient’s medical status.

Print name * Date * Signature (type your full name) *

Acknowledgment of Financial Responsibility

We are providing a professional service at a reasonable fee. Payment is expected at the time of service. Payment may be made in the following ways:
CashCheckVisa / MasterCard / Discover
Insurance estimates are provided as a courtesy. In the event that your insurance carrier pays less than the estimated amount, you are responsible for the unpaid balance.
We do not invoice patients. All balances must be paid at the time of service. This also allows us to keep our fees as low as possible.
Monthly Payment Program: We have contracted with Care Credit to provide a monthly payment program to our patients. This service allows you to make small monthly payments and has an interest free option.
Discounts: Our policy is not to discount for any reason. This allows our practice to keep our fees as low as possible.
Missed appointments: Appointments are considered confirmed at the time it is scheduled. I understand the office will try to contact me at the numbers I have provided in advance to confirm my appointment as a courtesy. I understand that the office reserves the right to charge for each broken appointment if adequate notice is not given. I understand that leaving a message after hours for the following day is not considered adequate notice since the office will not receive the message until the next working day.

I understand and agree to the above information

I have read and agree to the Acknowledgment of Financial Responsibility above. *

Financial responsibility — signature (type your full name) * Date *

Acknowledgement of Privacy Rights (HIPAA)

My signature confirms that I have been informed of my rights to privacy regarding my protected health information, under the Health Insurance & Accountability Act of 1996 (HIPAA). I understand that this information can and will be used to:

Provide and coordinate my treatment among a number of health care providers who may be involved in the treatment directly or indirectly.
Obtain payment from third-party payers for my health care services.
Conduct normal health care operations such as quality assessment and improvement activities.

I have been informed of my dental provider’s Notice of Privacy Practices containing a more complete description of the practices. I understand that my dental provider has the right to change the Notice of Privacy Practices, and that I may request to obtain a current copy.

I understand that I may request in writing that this office restrict how my private information is used or disclosed to carry out treatment, payment or health care operation. I understand that the office is not required to agree to my requested restrictions, but if the office does agree then it is bound to abide by such restrictions.

I have read and agree to the Acknowledgement of Privacy Rights (HIPAA) above. *

Privacy rights — signature (type your full name) * Date * Relationship to patient (if signed by a representative of patient)

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