New Patient FormPre-Visit Office FormPlease select from one of the forms below to fill out your pre-visit office form.First Name *Middle NameLast Name *Date *Age *SSN *0 / 9Street Address *Apartment, suite, etcCity *State *ZIP / Postal Code *Email Address *Mobile # *Home #Whom may we thank for referring you?NameRelationOther family members seen here?Name(s)Emergency ContactFirst Name *Last Name *Phone # *PhysicianPhysician's Name *Phone # *Are you currently under the physician’s care? *SelectYesNoExplain:0 / 200InsurancePerson responsible for insuranceName *Date *SSN *0 / 9Relationship to patient *Insurance company name *MedicationsPlease list all over the counter, prescription, herbal supplementsHave you been hospitalized in the last 2 years? *SelectYesNoExplain: *Have you ever had joint replacement/valve replacement? *SelectYesNoDate *Explain: *Have You ever had any of the following diseases or medical problems?Check all that applyAbnormal BleedingAcid RefluxAIDS/HIVAlcohol/Drug AbuseAnemiaArthritisArtificial Bones/Joints/ValvesAsthmaBlood TransfusionsCancer/ChemotherapyCold Sores/Fever BlistersColitisCongenital Heart DefectCOPDDiabetesDifficulty BreathingEmphysemaFainting SpellsFrequent HeadachesGlaucomaHay FeverHeart AttackHeart MurmurHeart SurgeryHemophiliaHepatitis AHepatitis B or CHigh Blood PressureHospitalized (any reason)HypoglycemiaKidney ProblemsLiver DiseaseLow Blood PressureLupusMitral Valve ProlapsePacemakerPsychiatric ProblemsRadiation TreatmentsRheumatic/Scarlet FeverSeizuresShinglesSickle Cell DiseaseSinus ProblemsSleep ApneaStrokeThyroid ProblemsTuberculosis (TB)UlcersVeneral DiseaseAre you allergic to any of the following?Check all that applyAspirinCodeinePenicillinTetracyclineErythromycinJewelry/MetalsLatexPlease list any other drugs/materials that you are allergic to:Please list any other medical conditions that you have had:FOR WOMEN ONLYAre you taking birth control medications?YesNoWhich birth control medications? *Are you pregnant?YesNoWeek #: *Are you trying to get pregnant?YesNoAre you nursing?YesNoWhat is the most important thing about your dental visit today?Date *OFFICE USE ONLYI verbally reviewed the medical/dentist information above with the patient names herein.InitialsDateDoctor’s Comments:NOTICE OF PRIVACY PRACTICESNOTICE OF PRIVACY PRACTICES: *By signing this form, I acknowledge that I have access to the Notice of Privacy Practices for SouthTowne Dental via the office or website at www.southtownedental.com. By signing this form, I also consent to SouthTowne Dental’s use and disclosure of my protected health information to carry out treatment, payment activities, and healthcare operations.RIGHT TO REVOKE: *You have the right to revoke consent at any time by giving us written notice of your revocation submitted to the Contact Person listed on the Notice of Privacy Practices. Please understand that revocation of this Consent will not affect any action we took reliance on this Consent before we received your revocation, but that we may decline to treat you or continue treating you if you revoked this Consent.SIGNATURE: *I have had a full opportunity to read and consider the contents of this consent form and your Notice of Privacy Practices. I understand that by signing this Consent form, I am giving my consent for your use and disclosure of my protected health information to carry out treatment, payment activities, and healthcare operations. I also give consent for any photos taken during my visit to be used on SoutheTowne Dental’s website and/or FacebookTM page for marketing and/or promotional purposes.Date *If this acknowledgement and Consent is signed by a parent/legal guardian/personal representative on the behalf of the patient, please comment the followingParent/Legal Guardian/Representative’s Name:Relationship to client:DateREVOCATION OF CONSENT: *I revoke my Consesnt for your use and disclosure of my protected health information for treatment, payment, activities, and healthcare operations. I understand that revocation of this consent will not affect any action you took in reliance on my Consent before you received this written Notice of Revocation. I also understand that you may decline to treat or continue to treat me after I have revoked my Consent.Date ***You are entitled to a copy of this consent after you sign it. This form will be retained in your dental record.DISCLAIMER – Consent to treatTo the best of my knowledge, the questions in this form have been answered accurately. I understand that providing incorrect or incomplete information can be dangerous to my (or the patient’s) health. It is my responsibility to inform the dental office of any changes in medical status. The undersigned hereby authorizes the Doctor, in order to make a thorough diagnosis of the patient’s dental needs, to take X-rays, study models, photographs or any other diagnostic aids deemed appropriate by the Doctor. I understand the Doctor will advise me of any and all forms of treatment, medication, and therapy that may be indicated in connection with the patient. I also understand that the Doctor may choose to employ such assistance as deemed fit. I further understand that use of anesthetic agents embodies certain risk. I understand that payment for dental services provided in this office for myself or my dependents is my responsibility, due and payable at the time that services are rendered, unless finiancial agreements have been previously made. A 1.5% monthly finance charge will be applied to all accounts over 90 days past due. There will be a $35 service charge on all returned checks. I understand that the Doctor’s office requires a 24 hour notice for appointment cancellations, and that I may be charged for each appointment cancelled less than 24 hours in advance. In the event of default, I (we) promise to pay legal interest on the indebtedness, together with such collection costs and reasonable attorney fees, as may be required to effect collection of this note. Please sign your name here, verifying that all information provided is true and complete.InsuranceOur Policy Regarding Dental InsuranceYou are fortunate to have dental insurance, whether you have purchased it or your employer has provided it for you. Though your dental insurance is your responsibility we can help! We will go the extra mile to help you maximize your benefits. As a courtesy, we will help by filing your insurance forms, which will save you considerable time and trouble. We accept payments from most insurance companies, which reduces your immediate out-of-pocket expense. Please remember, however, the financial obligation for dental treatment is between you and this office, and is not between this office and your insurance company. Regardless of what we may calculate your insurance company to pay, it is only an estimate. Our estimate is based on limited information obtained from your insurance company. You must understand, we cannot forecast what they will pay. We must stress that you are responsible for the total treatment fee. Your dental insurance is not designed to pay the entire cost of your treatment, but it is intended to help cover a certain portion of the cost. Better terms for dental insurance may be "dental assistance” or “dental benefits." In order for us to obtain your insurance information for submitting your claim and/or discuss your situation directly with your insurance, please complete the “Insurance Information” portion on the front page of the new patient packet.Date *Submit
