ABCDDS Adult
New Patient Form

Thank you for choosing our office for your dental care. All information in this form is confidential and transmitted over a secure, encrypted connection and will not be sold to any third party. We are fully compliant with all HIPAA Regulations.

(*) indicates a required field.

1. Tell Us About Yourself

Today's Date *
/ /

Full Name *

Nickname

Gender *

Family Members We Treat

Birthdate *
/ /

Preferred Contact Number

Social Security Number *

Home Address *

Street Address *

Apt #

City *

State *

Zip Code *


2. Who May We Thank For Referring You?

Name


3. Person Responsible for Account

Name *

Relationship

Billing Address

Apt #

City

State

Zip Code

Work Number

Home Number *

Cell Number

Email Address


4. Primary Dental Insurance

Insurance Company Name

Insurance Co. Address

Unit #

City

State

Zip Code

Insurance Co. Phone

Group # (Plan, Local or Policy #)

Policy Owner's Name

Relationship to Patient

Policy Owner's Birthdate
/ /

Policy Owner's SSN

Policy Owner's Employer


5. Secondary Dental Insurance

Insurance Company Name

Insurance Co. Address

Unit #

City

State

Zip Code

Insurance Co. Phone

Group # (Plan, Local or Policy #)

Policy Owner's Name

Relationship to Patient

Policy Owner's Birthdate
/ /

Policy Owner's SSN

Policy Owner's Employer


6. Dental History

Name of Previous Dentist and Location

Date of Last Exam
/ /

Do your gums bleed while brushing or flossing?

Are your teeth sensitive to hot or cold liquids/foods?

Are your teeth sensitive to sweet /sour liquids/foods?

Do you feel pain to any of your teeth?

Do you have any sores/lumps in or near your mouth?

Have you had any head, neck or jaw injuries?

Have you ever experienced any of the following?

Problems in your jaw?

Clicking?

Pain (joint, ear, side of face)?

Do you feel pain to any of your teeth?

Difficulty in opening or closing?

Difficulty in chewing?

Do you have frequent headaches?

Do you clench or grind your teeth?

Do you bite your lips or cheeks frequently?

Have you ever had any difficult extractions?

Have you ever had any prolonged bleeding following extractions?

Do you wear dentures or partials??

If yes, date of placement
/ /

Have you ever received oral hygiene instructions regarding the care of your teeth and gums?

Do you like your smile?


7. Health History

Have you ever had any of the following conditions? *

High Blood Pressure

Allergies to Any Drugs

Any Hospital Stays

Any Operations

Asthma

Cancer

Cardiac Pacemaker

Angina

Frequently Tired

Anemia

Emphysema

Arthritis

Joint Replacement/Implant

Handicaps/Disabilities

Hearing Impairment

Heart Disease/Murmur

Hepatitis

HIV + / AIDS

Kidney/Liver Conditions

STD

Ulcers

Chest Pains

Easily Winded

Stroke

Hay Fever/ Allergies

Radiation Therapy

Heart Attack

Convulsions/Epilepsy

Swollen Ankles

Tuberculosis

Fainting/Seizures

Low Blood Pressure

Glaucoma

Recent Weight Loss

Liver Disease

Heart Trouble

Respiratory Problems

Mitral Valve Prolapse

Other

Rheumatic/Scarlet Fever

Allergies to Latex Product

Diabetes

Hemophilia/Blood Disorders

Leukemia

Thyroid Problem

Have you ever taken Fen-Phen/Redux?

Do you use tobacco?

Do you use controlled substances?

Are you wearing contact lenses?

Do you have a persistent cough or throat clearing not associated with a known illness (lasting more than 3 weeks)?

Women Only:

Are you pregnant?

Are you nursing?

Are you taking oral contraceptives?

Please discuss any serious medication conditions you have had: (or write NONE) *

Please list all the drugs you are currently taking: (or write NONE) *

Please list all drugs you are allergic to: (including Local Anesthetics (e.g. Novocain), Penicillin or any other Antibiotics, Sulfa Drugs, Barbiturates, Sedatives, Iodine, Asprin, Any metals (e.g. nickel, mercury, etc.), Latex Rubber, other, or write NONE) *

Your Physician *

Phone Number

Are you currently under the care of a physician? *

Please describe your current physical health *

8. ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

You May Refuse to Sign This Acknowledgment

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

  1. Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
  2. Obtain payment from third-party payers.
  3. Conduct normal healthcare operation such as quality assessments and physician certifications.

I have received, read, and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or healthcare operation. I also understand you are not required to agree to my requested restriction, but if you do agree then you are bound to abide by such restrictions.

Signature *
(Please use your mouse or finger on a touchscreen to sign in the box.)

 

Relationship to Patient *

Date *
/ /

9. REQUEST FOR CONFIDENTIAL COMMUNICATIONS

Full Name

Date of Birth

I request that all communications to me by ABC Dentistry & Orthodontics and/or the staff be handled as follows:

Written Communications:

Address To

Email Communications:

Address To

Would you like to receive emails?

Oral Communications:

Home #

May we leave a message?


Work #

May we leave a message?


Cell #

May we leave a message?


I prefer to be contacted at

Would you like to receive text messages?

May we leave a message that you need pre-medication?

May we leave a message that you have dental appointment?

OFFICE-USE ONLY

I attempted to obtain the patient's signature in acknowledgment on this Notice of Privacy Practices, but was unable to do so as documented below.

Date
___________________________________

Initials
___________________________________

Reason
___________________________________

Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.


10. Signature

I understand that the information I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform the necessary dental services I may need.

Signature *
(Please use your mouse or finger on a touchscreen to sign in the box.)

 

Relationship to Patient *

Date *
/ /