New Patient Intake - Divine Dental Clinic

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PATIENT INFORMATION

Please answer the following questions to help us to better care for your dental needs. All information will be confidential and is for our records only.

Role*

Mrs

Miss

Mstr

Other

other

First Name*

Last Name*

Sex

Male

Female

Other

Birth Date*

YYYY dash MM dash DD

Phone - Home

Phone - Work

Cell Phone*

Unit / Building

Street Address

City

Postal Code

Email*

How did you hear about us?*

Name of referral*

How did you hear about us*

MEDICAL HISTORY

Name of Physician/Clinic

Phone

Women only – are you pregnant? If yes what is due date?*

Yes

Due Date:*

YYYY dash MM dash DD

Have you been hospitalized in the past 5 years? If yes for what reason?*

Yes

Reason for hospitalization

Have you ever had an unusual reaction/ allergy to any medication? (i.e.: penicillin, codeine, local anesthetic, sulpha, NSAIDs, etc)

If you have any disease, condition or problem not mentioned about, please describe

Please list medications you are currently taking (prescription and/or non-prescription)

Do you smoke? (tobacco, marijuana ,other) How many per day and for how long?

Please check all of the conditions that you have now or have had in the past

conditions that you have now or have had in the past

Asthma/Hay Fever

Cancer

Diabetes

Sinus Trouble

AIDS/HIV+

High/Low Blood Pressure

Heart Murmur

Heart Attack/Surgery

Artificial Joints/Heart Valves/Pacemaker

Frequent Alcohol Consumption

Epilepsy/Seizure Disorder

Substance Abuse

Arthritis/Rheumatism

STD’s

Stomach Disorders

Psychiatric Disorders

Lung Disease/Tuberculosis

Hepatitis/Jaundice/Liver DiseaseAIDS

Frequent/Severe Headaches

Thyroid Disease

Blood Disorders/Anaemia

DENTAL HISTORY

Name of previous dentist/clinic

Date of last dental visit

YYYY dash MM dash DD

Reason for visit with us

1) Have you ever had regular dental visits in the past? (If yes, please explain.)*

Yes

Explain for Question 1

2) Are you currently having any dental pain? (If yes, please explain.)*

Yes

Explain for Question 2

3) Have you been treated for periodontal (gum) disease in the past? (If yes, please explain.)*

Yes

Explain for Question 3

4) Is there a family history of periodontal (gum) disease? (If yes, please explain.)*

Yes

Explain for Question 4

5) Do your gums bleed when you brush or floss? (If yes, please explain.)*

Yes

Explain for Question 5

6) Are you aware of any sores or lumps in your mouth? (If yes, please explain.)*

Yes

Explain for Question 6

7) Do you get popping or clicking sounds from your jaw? (If yes, please explain.)*

Yes

Explain for Question 7

8) Are you aware of clenching or grinding your teeth? (If yes, please explain.)*

Yes

Explain for Question 8

9) Have you had surgery/radiation treatment to your head/neck? (If yes, please explain.)*

Yes

Explain for Question 9

10) Have you ever had orthodontic treatment (braces)? (If yes, please explain.)*

Yes

Explain for Question 10

11) Have you ever had a bad reaction or abnormal bleeding with past dental procedures? (If yes, please explain.)*

Yes

Explain for Question 11

12) Have you had any trauma to your face or jaw? (If yes, please explain.)*

Yes

Explain for Question 12

How often do you floss?

How often do you brush your teeth?

When receiving dental treatment would you consider yourself:

Are you interested in receiving minimal sedation while receiving dental treatments?

Yes

Is there anything about the appearance of your teeth that concerns you?

Yes

Please explain.

What concerns you most about receiving dental treatment?

What, if any, is/are your current dental issue(s)?

Consent to Treatment:

I certify that the above information is correct to the best of my knowledge.
I authorize the doctor upon consultation and direct consent from the patient/parent/guardian to perform diagnostic procedures, treatment, and medication in the connection with the patient’s dental needs.
I understand that responsibility for payment of dental services, including insurance or otherwise, is due and payable at the time services are rendered and despite any dental insurance. I am ultimately responsible for any fees withheld by the insurance company.

Relationship

Date*

YYYY dash MM dash DD

Signature*

OFFICE POLICY REGARDING DENTAL PLANS

Name of Insurer

Certificate or ID #

Group or Plan #

Plan Holder name (if not yourself)

Date of Birth*

MM slash DD slash YYYY

As a courtesy and convenience to you, our patient, Divine Dental Clinic accepts dental plans upon confirmation of your coverage and the information your insurance company discloses. Based on this information, we are able to provide you with estimates of treatment required to the best of our knowledge.

Your dental policy is a contract between you, your employer, and your insurance company. Should your coverage terminate or change in any way, we can only be notified of this by YOU, the patient. If treatment is not paid by your dental plan, it is the sole responsibility of you, the patient, to cover all costs.

We bill all treatment done on the day the service is rendered. If we have not received payment from your insurance company within 60 days of services rendered, then this claim becomes your responsibility. Any portion of any claim submitted to your insurance company that is not paid in a timely manner will become your responsibility.

Payment for services rendered is expected in full upon us notifying you by phone, email, or mail. Should payment not be made, Divine Dental Clinic may exercise the right to transfer your account to a Debt Collection Agency.

OFFICE rescheduling policy:

Our office kindly requests 2 full business days' notice for an appointment change. A missed appointment fee of $100 will be charged if insufficient notice is provided. Some appointments over 1 hr may require a deposit (treatment dependent). All meetings scheduled within 24hrs will be considered confirmed at the time of booking. We offer an automated reminder service to ensure you are notified and reminded of all appointments scheduled with us.

I have read and understand the above and agree with the terms and conditions.

Name

Date*

YYYY dash MM dash DD

Signature*

Name

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