New Patient Form

Form

Patient Registration Form.

Date:
P.ID:

Welcome to Sweet Tooth Dentistry, your dental home! Our office looks forward to provide you with exceptional dental care. To assist us in serving you better, please complete both sides of the following confidential form.

First Name:     Last Name:     Prefer to be called:
Date Of Birth:       Age:         Gender:    
Address:         City:         Postal Code:    
Cell Phone:       Home Phone:       Work Phone:  
Best Way To Contact:                                Best Time To Contact:      
May we contact you by Text/Email          Intials:     Email:      
How did you hear about us:       Are other family members pt. at our office:           Name:    
Emergency contact:       Phone:       ID for prescription:  
Family Physician:       Phone:       Address:  
Financial Agreement / Authorization
Person Responsible for Account    
Name:       Relationship:       Phone No.:  

Minors must be accompanied by a parent or legal guardian. If the parents are not together, the person accompanying will be responsible for the treatment and payment of the service. We accept the following forms of payment: Cash/ Card/ Insurance Assignment. We do not accept personal cheques. Please provide following information for assignment purposes.

Primary Insurance Plan

Name:
DOB:
Occupation:
Employer:
Group No.:
Policy No.:
 

Secondary Insurance Plan

Name:
DOB:
Occupation:
Employer:
Group No.:
Policy No.:
 

As a professional courtesy to our most valued patients, we will accept insurance assignment under the following terms and conditions:

1. Any amounts not paid for under your insurance plan and due to our office will be paid by you. Payment is due at the time of service, including any deductibles or co-payments. 2. When your treatment requires laboratory services, a deposit equal to the estimated laboratory fee is required at the time that your dental impressions are taken. 3.While we will do our best to obtain accurate information regarding your eligibility and benefits, in some cases the insurance companies will not provide us with the most up to date information resulting in inaccuracies. No estimate is a guarantee of payment. Please understand, you are responsible for all charges not paid by your insurance. Also, many insurance companies are excluding certain dental procedures or downgrading procedures to a lesser reimbursement level; in which case, you would be responsible for the difference. 4. If full payment has not been made within 30 days of the claim submission any outstanding balance will be your responsibility should your insurance company deny all, or a portion of your claim. The balance will be charged to your credit card on file and a receipt of any charges will be mailed to you. I have read or have had read to me the privacy and office policies and insurance assignment conditions. I understand that I am responsible to pay for all dental fees charged to me for services provided. My signature below is authorization of the assignment of my Dental Insurance payment to Sweet Tooth Dentistry. If my plan denies payment of my benefits to Sweet Tooth Dentistry, I agree to pay my account in full.
Signature of Patient, Parent or Guardian:       Date:       Witness:  
I hereby authorize Sweet Tooth Dentistry to process payment to my credit card of any outstanding balance for dental treatment.
Credit Card No:       CVV:       Exp. Date:  
Name on Card:       Signature:       Date:  
Your appointment will be reserved just especially for you. If you are unable to keep the appointment we will require 48 hours notice, otherwise it will be necessary to charge for the time lost.

Please do not hesitate to ask our staff should you have any question regarding any office policy. (Turn page)

Medical and Dental history: Name:   Age:   Date:

Please do not hide any information. Any unrevealed information may affect your treatment. Please fill appropriate boxes:

1. Reason for today’s visit?  
2. Does any of your teeth hurt?  
3. When was your last dental cleaning and check-up?  
4. Previous dentist visited:  
5. Ever had dental:   Injury   Surgery   Gum Surgery   Braces
6. Is your sugar/snack intake:      
7. Do you floss regularly?    
8. Brushing:       How often? /day
9. Do you have any concerns regarding dental visit? Time   Money  Fear   Other  
10.Do you have other dental concern? 
11. Do your gums bleed when: Brushing Flossing Spontaneously
12. Do you suffer from pain and /or swelling of your gums?    
13. Are you aware of any loose teeth?    
14. Are any of your teeth sensitive to?  Cold Sweet Heat Other
15. Do you grind or clench your teeth during the day or night?
16. Does your jaw click or pop when opened widely?    
17. Do you have any difficulty in opening or closing your jaw?
18. Do you feel dry mouth during day time?    
19. Have you had any growth or sore spots in your mouth?
20. Would you rate your current dental health as:
Medical History
Do you currently have or previously had any of the following:
 Angina, Chest Pain  Shortness of Breath  Heart Attack  Heart Disease  Artificial Heart Valve  Pacemaker  Infective Endocarditis  Heart Murmur
 Diabetes  Hypoglycemia  Hepatitis A, B, C  Implant/Transplant  AIDS/HIV  Cancer/Malignancy  Artificial Joints  Radiation/chemotherapy
 High Blood Pressure  Low Blood Pressure  Dizziness/Fainting  Bleeding Disorder  Anemia  Stroke  Alcohol Dependency  Drug Dependency
 Respiratory/Lung Disease  Kidney Disease  Liver Disease  Stomach Ulcers  Psychiatric Condition  Epilepsy/Seizures  Cerebral Palsy  None
 Thyroid Condition  Tuberculosis  Asthma  Sinus Problems  Arthritis  Osteoporosis Medication  Bulimia  Others
1. Are you presently under the care of a physician?    
2. Have you had a medical examination in the last year?    
3. Have you ever been hospitalized for illness or surgery?    
4. Do you use any prescription or non-prescription drugs?     Please List:
5. Have you been warned against taking any medication?     Please List:
6. Do you have any allergies?     Please List:
7. Have you ever had any injury or surgery to face or jaw?    
8. Do you have frequent / severe headaches?  
9. Do you bruise or bleed abnormally/more?  
10. Is there any medical condition that runs in the family? (Like Diabetes, High blood pressure, Cancer, etc.)     Please List:
11. Do you faint (pass out) frequently?    
12. Have you ever had any heart condition?    
13. Have you had any recent change to your health?    
14. Is there anything about you we should be aware of?     Please List:
15. Do you smoke?  If yes, No. of years Cigr./day
16. Have you ever smoked?    
17. Do you smoke pot/weed?   ; Smoked in last 24hrs?
18. Women: Pregnancy     Breastfeeding:       OCP:      
I understand that the information that I have given today is correct to the best of my knowledge and haven’t omitted any information. I also understand that it is my responsibility to inform this office of any changes in my medical status. I have had the opportunity to ask questions and I also consent my physician being contacted if necessary. I hereby authorize the dentist or designated staff to perform diagnostic, dental and oral surgery procedures and services.
Notes:  BP:  Hb1AC/B.Sugar: 
Patient/ Parent’s (Guardian) Signature:       Date:       Dentist:  

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