Welcome!
Please enter the patient's name below:
First Name
Last Name
New Patient Welcome
We welcome the opportunity to be of service to you and your family. To best serve your dental health needs, we wish to acquaint you with our office policies.
APPOINTMENTS:
Once an appointment is made, please remember this time has been reserved for you. A minimum charge of $200 will be made for failed or cancelled appointments without prior notification of 48 hours.
INSURANCE:
An insurance policy is an agreement between the patient and the insurance company. The patient is responsible for payment of all fees. We do not render our services on the basis that the Insurance Company will pay all our fees. Most insurance companies pay only a portion of the dental investment. Although we are happy to file the necessary forms to see that you receive the full benefits of your coverage, we make no guarantee of any estimated coverage. We will file primary insurance, and secondary insurance when patient provides EOB. All insurance co-payments and payments of services not covered by insurance are due and payable at each visit.
For treatments requiring multiple appointments, such as crowns, inlays, onlays, veneers, dentures and root canals, payment is due at first visit.
COURTESY:
For your convenience we offer the following payment options:
1. Cash (2% discount)
2. Personal Checks (with driver’s license) (2% discount)
3. Credit Cards (Mastercard, VISA, Discover or AMEX)
4. Care Credit (extended payment plan if qualified)
5. Springstone (extended payment plan if qualified)
If at anytime you have questions regarding any treatment or service, please discuss them with us promptly and frankly. We will make every effort to address your concerns.
Signature of Responsible Party
Clear
Date
Dental Health History
Date of last health care exam
What was this exam for?
Have you been hospitalized in the last 5 years?
Yes
No
Explain:
Health Conditions
For the following questions, select Yes or No. Your answers are for our records only and will be confidential. Please note that during your initial visit you will be asked some questions about your response. Our team may ask additional questions concerning your health
Heart Murmur (mitral valve prolapse)
Yes
No
Psychosis
Yes
No
Anemia
Yes
No
Sore/Enlarged Lymph Nodes
Yes
No
Diabetes
Yes
No
Previous Biopsies
Yes
No
Epilepsy
Yes
No
Slow-Healing Mouth Sores
Yes
No
Hepatitis, Any Form
Yes
No
Other Infections
Yes
No
Rheumatic Fever
Yes
No
Recurrent Illnesses
Yes
No
Asthma
Yes
No
Joint Replacement
Yes
No
HIV Positive or AIDS Related Complex
Yes
No
Glaucoma
Yes
No
Emphysema or other Respiratory Illnesses
Yes
No
Abnormal Bleeding From a Cut
Yes
No
Abnormal Heart Condition
Yes
No
Liver Disease (including Jaundice)
Yes
No
Kidney Disease
Yes
No
Unintentional Weight Loss/Gain
Yes
No
Heart (Surgery, Disease, Attack)
Yes
No
Latex Sensitivity
Yes
No
Venereal Disease
Yes
No
Other
Yes
No
If other, please explain:
Are you required to Pre-Medicate before dental treatment?
Yes
No
If yes, what medication:
Female Patients
Are you a female patient?
Yes
No
Other Medical Conditions
Abnormal Blood Pressure?
Yes
No
If yes, what is it usually:
Are you allergic or have you had a reaction to:
Local anesthetics
Yes
No
Penicillin or other antibiotics
Yes
No
Aspirin
Yes
No
Codeine, valium or other sedatives
Yes
No
Other
Yes
No
If other, please list:
Are you a smoker?
Yes
No
If so, how much do you smoke per day?
Please list any medications you are currently taking:
Are you taking Tagamet (Cimetidine)?
Yes
No
If yes, how often?
Do you take Antacids?
Yes
No
If yes, how often do you take Antacids?
Are you taking herbal supplements/medications?
Yes
No
If yes, how often are you taking herbal supplements/medications?
Diet
Are you on a Restricted Diet?
Yes
No
If yes, how many meals a day?
Do you have any Food Allergies?
Yes
No
If yes, to what?
Sugar in your diet:
None
Slight
Moderate
High
Headaches, TMJ pain
Do you have Severe Migranes: 15 days/month, 4 hrs minimum?
Yes
No
Do you have Occasional or Mild Migrane headaches?
Yes
No
Do you have TMJ pain?
Yes
No
Do you use a Night Guard?
Yes
No
Have you received any Botox or Dermal Fillers in the past?
Yes
No
Any other issues regarding your medical or dental history?
Dental management special requests:
Signature
Patient Signature
Clear
Date today:
IN OFFICE USE ONLY
Are you a member of staff? If no, please proceed and submit this form.
Yes
No
Sleep Assessment Form
Your doctor is requesting that you complete this Sleep Assessment Form. This form determines the need for you to have a user friendly home sleep test, which will test to see if you have a challenge breathing when you are sleeping. How you breathe can affect your quality of life and especially your cardiovascular health; and can be easily treated.
Date of birth
OK to leave Message?
Yes
No
Regular Dr’s Name
Regular Dr’s Phone
Sleep Questionnaire
Have you ever been given a CPAP device?
Yes
No
If you have been given any form of CPAP, do you use it nightly?
Yes
No
Are you comfortable with your CPAP and satisfied with its use?
Yes
No
If the answer is YES to the all of the above questions, PLEASE STOP. and submit the form.
If your answer is NO to any of the above questions, please continue to the following questions:
Sleepiness Scale
How likely are you to doze off while doing the following activities? Please use the following scale:
0 = never
1 = slight
2 = moderate
3 = high
Being a passenger in a motor vehicle for an hour or more
0 = never
1 = slight
2 = moderate
3 = high
No elements found. Consider changing the search query.
List is empty.
Sitting and talking to someone
0 = never
1 = slight
2 = moderate
3 = high
No elements found. Consider changing the search query.
List is empty.
Sitting and reading
0 = never
1 = slight
2 = moderate
3 = high
No elements found. Consider changing the search query.
List is empty.
Watching TV
0 = never
1 = slight
2 = moderate
3 = high
No elements found. Consider changing the search query.
List is empty.
Sitting inactive in a public place
0 = never
1 = slight
2 = moderate
3 = high
No elements found. Consider changing the search query.
List is empty.
Lying down to rest in the afternoon
0 = never
1 = slight
2 = moderate
3 = high
No elements found. Consider changing the search query.
List is empty.
Sitting quietly after lunch without alcohol
0 = never
1 = slight
2 = moderate
3 = high
No elements found. Consider changing the search query.
List is empty.
In a car, while stopped for a few minutes in traffic
0 = never
1 = slight
2 = moderate
3 = high
No elements found. Consider changing the search query.
List is empty.
Part 1
Have you been told that you snore?
Yes
No
Does your family have a history of premature death in sleep?
Yes
No
Do you have Diabetes?
Yes
No
Have you ever been told you have Coronary Artery Disease?
Yes
No
Have you been told that you have high blood pressure?
Yes
No
Have you ever experienced an irregular heart beat?
Yes
No
Part 2
Are you taking opioid pain medications on a regular basis?
Yes
No
Have you ever been diagnosed with sleep apnea?
Yes
No
Do you awaken from sleep with chest pain or shortness of breath?
Yes
No
Has anyone said that you seem to stop breathing while sleeping?
Yes
No
Is your neck size larger than 15” (female) or 16.5’’ (male)?
Yes
No
Neck Size
Have you ever had a stroke?
Yes
No
Have you ever been told you have congestive heart failure?
Yes
No
Do you have or did you ever have atrial fibrillation?
Yes
No
Signature
Patient's Signature
Clear
Today's date
IN OFFICE USE ONLY
Are you a staff member?
Yes
No