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Patient of Advanced Smiles
Please complete and submit this form prior to your initial dental appointment.
Section A: PATIENT INFORMATION
FIRST Name *
Your answer
LAST Name *
Your answer
Middle Initial
Your answer
Preferred/Nickname
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Status *
Gender *
Age *
Your answer
Social Security # *
Your answer
Address *
Your answer
City, State *
Your answer
Zip *
Your answer
Email Address *
Your answer
Phone (Home) *
Your answer
Phone (Mobile) *
Your answer
Phone (Work)
Your answer
Whom may we thank for referring you? *
Name of person, office or other source referring you to our practice:
Your answer
Emergency Contact *
Name
Your answer
Emergency Contact Phone # *
Your answer
Section B: RESPONSIBLE PARTY INFORMATION
Is Responsible Party the Patient?
If so, check self and skip to Section C: Insurance Information
FIRST Name
Your answer
LAST Name
Your answer
Relationship to Patient
Your answer
Phone
Your answer
Address
Your answer
City, State
Your answer
Zip
Your answer
Social Security #
Your answer
Date of Birth
MM
/
DD
/
YYYY
Section C: INSURANCE INFORMATION
Is the patient actively insured under a DENTAL INSURANCE PPO PLAN?
Insurance Carrier
Your answer
Employer
Your answer
Primary Subscriber's FIRST Name
Your answer
Primary Subscriber's LAST Name
Your answer
Primary Subscriber's Date of Birth
MM
/
DD
/
YYYY
Subscriber ID
Your answer
Group
Your answer
Insurance Phone
Your answer
Section D: MEDICAL HISTORY
What is your current HEIGHT? *
Your answer
What is your current WEIGHT? *
Your answer
Do you have any CURRENT health problems? *
Are you under a PHYSICIAN'S care now? *
If YES, what for?
Your answer
PHYSICIAN'S Name
Your answer
Are you currently taking any medications? *
Medications List
Your answer
Are you pregnant? *
Are you nursing?
Do you smoke or use tobacco? *
Primary care provider's name: *
Your answer
Primary care provider's phone number:
Your answer
Health Conditions/Concerns
Check any of the following which you have had or have at present.
Other Medical Alerts
List any other health conditions/concerns that you would like us to know about.
Your answer
Section E: DENTAL HISTORY
Previous Dentist's Name, Address, Phone *
Your answer
How LONG SINCE you have seen a dentist? *
Your answer
Last COMPLETE dental exam with X-RAYS date *
Your answer
Are you having DENTAL PROBLEMS NOW? *
If YES, What DENTAL PROBLEMS/CONCERNS would you like addressed?
Your answer
Do you wear DENTURES? *
Do your GUMS BLEED, or feel TENDER, or IRRITATED? *
Are you SENSITIVE to hot, cold, sweets, or pressure? *
Are you UNHAPPY with the APPEARANCE OF YOUR TEETH? *
Have you had any PERIODONTAL (GUM) treatments? *
Are you aware of GRINDING and/or CLENCHING your teeth? *
Have you ever had a serious/difficult problem associated with any PREVIOUS DENTAL WORK? *
Do you have LOOSE, TIPPED or SHIFTING teeth? *
Would you like your smile to LOOK BETTER or DIFFERENT? *
Have you worn BRACES or had any kind of Orthodontics on your teeth? *
Do you have DISCOLORED teeth that bother you *
Do you have problems with teeth/fillings BREAKING? *
How many times a day do you BRUSH? *
Your answer
How many times a week do you FLOSS? *
Your answer
Section F: HIPAA
Consent to HIPAA *
I hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION AND CONSENT FORM. I understand that checking the box and typing my full name below serve as my signature and consent to the terms of the HIPAA INFORMATION AND CONSENT FORM.
Required
*
Signature of Patient/Guardian/Responsible Party (Type full name)
Your answer
Section G: ASSIGNMENT OF INSURANCE BENEFITS
Consent to Assignment of Insurance Benefits *
I hereby authorize the assignment of insurance benefits to Advanced Smiles. I understand that checking the box and typing my full name below serve as my signature and consent to allow Advanced Smiles to file dental insurance claims on my behalf, therefore receiving payment directly for services rendered and covered by my insurance. (Please check box below even if you are not currently insured. Your consent to assign insurance benefits to Advanced Smiles will be needed if you ever decide to use any kind of benefit program at our office.)
Required
*
Signature of Patient/Guardian/Responsible Party (Type full name)
Your answer
Section H: RELEASE OF INFORMATION
I authorize the release of information including the diagnosis, records; examination rendered to me and claims information. This information may be released to: *
List names of people that your healthcare information may be released to.
Your answer
Consent to Release of Information *
I hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM and dictated by the preceding RELEASE OF INFORMATION FORM. I understand that this consent shall remain in force from this time forward until terminated by patient in writing. I understand that checking the box and typing my full name below serve as my signature and consent to the terms of the Release of Information.
Required
*
Signature of Patient/Guardian/Responsible Party (Type full name)
Your answer
Section I: Comprehensive Authorization Consent
I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I authorize the release of any information concerning my (or my child’s) health care, advice, and treatment provided for the purpose of evaluating and administering claims for insurance benefits. I authorize the release of any information concerning my (or my child’s) health care, advice and treatment to another dentist. I hereby authorize payment of insurance benefits directly to the dentist or dental group, otherwise payable to me. I understand that my dental care insurance carrier or payer of my dental benefits may pay less than the actual bill for services. I understand I am financially responsible for payments in full of all accounts. By signing this statement, I revoke all previous agreements to the contrary and agree to be responsible for payments of services not paid, in whole or in part by my dental care payer. I attest to the accuracy of the information on this page. I understand that checking the box and typing my full name below serve as my signature and consent to the terms of the Comprehensive Authorization Consent. *
Required
*
Signature of Patient/Guardian/Responsible Party (Type full name)
Your answer
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