NEW PATIENT FORMS IN POMERADO FAMILY DENTAL

First Visit

Medical History for New Patient

"*" indicates required fields

About You

Last Name*

First Name*

Birthdate*

Preferred Name

Gender

Email Address*

Home Phone*

Wireless Number

Work Number

City

State / Province

Zip / Postal Code

Emergency Contact

Phone

Relationship

Workplace

Phone

SSN

- Medical History -

Do you have a personal physician?

Yes

Physician's Name*

Phone Number*

Date of last visit*

Your current physical health is*

Good

Fair

Poor

Are you currently under the care of a physician?*

Yes

Please Explain*

Do you smoke or use tobacco in any other form?*

Yes

Have you have any metal rods, pins or implants?*

Yes

Are you taking any prescription/over the counter drugs?*

Yes

List all medications that you are now taking:

Tobacco use? If so, what kind and how much?

Have you ever taken Phen-Fen? (AKA Redux or Pondimin)*

Yes

Other

Have you ever taken Fosamax, or anyother bisphosphonate?*

Yes

For Women:

Are you using a prescribed method of birth control?

Yes

Are you pregnant?

Yes

Other

Are you nursing?

Yes

Do you have any of the following diseases or medical problems?*

Please list any serious medical condition(s) that you have ever had:

Not that I am aware of

Other

Are you allergic to any of the following?*

Please list any other drugs / materials that you are allergic to:

Dental History

Do you have a Panoramic x-ray or Full Mouth x-rays that are less than 5 years old?

Yes

Do you have BiteWing x-rays that are less than 1 year old?

Yes

Name of former dentist*

City*

State / Province*

Date of last cleaning and exam

Yes

None

Date*

Why have you come to the dentist today?*

Are you currenty in pain?*

Do you require antibiotics before dental treatment:*

Yes

Your current dental health is:*

Good

Fair

Poor

Have you ever had a serious / difficult problem associated with any previous dental work?*

Yes

Do you floss daily?*

Yes

Other

Do you brush daily?*

Yes

Type of bristles on your toothbrush?*

Hard

Medium

Soft

Do your gums ever bleed?*

Yes

Ever itch?

Yes

Have you ever been told you have periodontal disease?*

Yes

Do you now or have you ever experienced pain / discomfort in your jaw joint (TMJ / TMD) ?*

Yes

Are your teeth sensitive to heat, cold or anything else?*

Yes

Other

Do you have any loose teeth?*

Yes

Do you still have wisdom teeth?*

Yes

Would you like fresher breath?*

Yes

Whiter teeth?*

Yes

Are you happy with the way your smile looks?*

Yes

If not, what would you change?*

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibilty to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need durring diagnosis and treatment, with my informed consent.

Signature*

Max. file size: 100 MB.

Payment is due in full at the time of dental treatment Unless prior arrangements have been approved

If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment. I hereby authorize release of any information, including the diagnosis and records of treatemnt or examination rendered, to my insurance company.

Signature*

Max. file size: 100 MB.

DENTAL OFFICE POLICY

Last Name:*

First Name:*

Birthdate:*

"Welcome! We appreciate your confidence in choosing us for your dental needs. We are committed to provide comfortable, personable, efficient and the highest quality dental care available. If you have any questions about these important office policies, please do not hesitate to ask our friendly staff.--- Dr. Sarju B. Patel and Staff PERSONAL INFORMATION: Please notify the front desk if there are any changes to your address, telephone number or insurance plans. PAYMENTS: Payment is due at the time of service(s). Additionally, if you have a balance from a previous visit following an insurance payment you will be responsible for payment. As a courtesy, we verify your eligibility of benefits and file a claim to your insurance. However, it is just an estimate and is NOT A GUARANTEE of payment or coverage. All services are a sole responsiblity of the patient, regardless of insurance payment. 3rd party financing is available for treatment for those patients who desire a "payment plan". (OAC) There is a $25.00 fee for all returned checks. There is a 1 1/2 % per month finance charge for all accounts over 30 days. CANCELLATIONS AND MISSED APPOINTMENTS: We require for you to notify the office at least two business days to reschedule or cancel an appointment, unless due to an emergency or valid reason. Non compliant patients will be charged a $100 fee per appointment hour. In fairness to all of our patients, we can not make exceptions to this policy. We will make every effort to remind you of your apppointment by call, text and/or email 2 days prior to your scheduled appointment. Also, please make note of your scheduled appointment time on your calendar as a self reminder. TREATMENT PLANS: We will provide you with a written treatment plan, including the estimated costs. All charges for services provided are ultimately your responsiblity, even if our original estimate differs from the final cost. We are happy to discuss your treatment plan and fees in detail prior to treatment and answer all of your questions. DENTAL INSURANCE: We accept most PPO and one HMO dental insurance plan. Insurance is a contract between you, your employer and the Insurance Company. We do not have any influence over these arrangements. It is your responsibility to understand your insurance benefits and limitations.* Each policy is different (sometimes even for patients with the same employer). We may not know in advance what services needed or desired will or will not be covered. You may request "Treatment Pre-determination", if applicable, to determine accurate insurance coverage for treatment. If your insurance plan and/or benefits change, it is your responsibility to let the office know for a better estimate. Our written treatment estimates are based upon verbal information provided to us by your insurance company and NOT A GUARANTEE of coverage. X-RAYS: X-Rays are one of the most important diagnostic tools used in the dental office. Our office uses a digital X-Ray sensor that minimizes radiation exposure, as much as 80-90%, compared to conventional film-based equipment. Our standard of care requires current X-Rays to check for decay, fractures, abscesses and other types of pathology in the teeth, roots and surrounding bone. We are unable to provide any dental care for patients that refuse X-Rays or provide any taken recently from another dental office. However, if you do not have any X-Rays with you, we will be glad to take the necessary X-Rays on your first visit. Based on insurance estimates and coverage, any fee of the X-Rays will be the patient's responsibility. LOCAL ANESTHETICS/ORAL MEDICATIONS: Our office uses Local Anesthetics for most of our restorative procedures. Local Anesthetics help avoid pain and discomfort during dental procedures. Antibiotics help reduce and eliminate dental infection and Analgesics help reduce pain. RECORDS: Your dental records are this office property. You may request a copy of your records and X-Rays by submitting a Release Form. There is a duplication fee of $10.00 for printing or mailing your records.

I agree to term and conditions:

Signature*

Max. file size: 100 MB.

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NEW PATIENT FORMS IN POMERADO FAMILY DENTAL

First Visit

Medical History for New Patient

About You

- Medical History -

For Women:

Dental History

DENTAL OFFICE POLICY

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