Marital Status:
Is the patient a Minor?:
Full-time Student?:
If patient is a Minor, primary residence:

Primary Insurance

Secondary Insurance


Whom may we thank for referring you?

Patient Responsibilities: We are committed to providing you with the best possible care and helping you achieve your optimum oral health. Toward these goals, we would like to explain your financial and scheduling responsibilities with our practice.

Payment: Payment is due at the time services are rendered. Financial arrangements are discussed during the initial visit and a financial agreement is completed in advance of performing any treatment with our practice. We accept the following forms of payment MASTERCARD, VISA, DISCOVER, CASH, CHECK. *Please note: If you elect to apply for third-party financing, administered through our practice, we are required by law to provide you with a Credit for Dental Services Notice.

Dental Benefit Plans: Your dental benefit is a contract between you or your employer and the dental benefit plan. Benefits and payments received are based on the terms of the contract negotiated between you or your employer and the plan. We are happy to help our patients with dental benefit plans to understand and maximize their coverage.
Our practice IS / IS NOT (circle one) a contracted provider with your dental benefit plan.

If we are a contracted provider with your plan, you are responsible only for your portion of the approved fee as determined by your plan. We are required to collect the patient’s portion (deductible, co-insurance, co-pay, or any amount not covered by the dental benefit plan) in full at time of service. If our estimate of your portion is less than the amount determined by your plan, the amount billed to you will be adjusted to reflect this.

If we are not a contracted provider with your dental benefit plan, it is the patient’s responsibility to verify with the plan whether the plan allows patients to receive reimbursement for services from out-of-network providers. If your plan allows reimbursement for services from out-of-network providers, our practice can file the claim with your plan and receive reimbursement directly from the plan if you “assign benefits” to us. In this circumstance, you are responsible and will be billed for any unpaid balance for services rendered upon receipt of payment from the plan to our practice, even if that amount is different than our estimated patient portion of the bill. If you choose to not “assign benefits” to our practice, you are responsible for filing claims and obtaining reimbursement directly from your dental benefit plan and will be responsible for payment to our practice before or at the time of service.

Scheduling of Appointments: We reserve the doctor and hygienist’s time on the schedule for each patient procedure and are diligent about being on-time. Because of this courtesy, when a patient cancels an appointment, it impacts the overall quality of service we are able to provide. To maintain the utmost service and care, we do require 48-hour notice to reschedule an appointment. With less than 48-hour notice, a fee of $50 or deposit to reserve the appointment time again, may be required. To serve all of our patients in a timely manner, we may need to reschedule an appointment if a patient is fifteen minutes late or more arriving to our practice. To reschedule an appointment due to late arrival, a fee of $50 or deposit to reserve the appointment time again, may be required.

Unencrypted email is not a secure form of communication. There is some risk that any individually identifiable health information and other sensitive or confidential information that may be contained in such email may be misdirected, disclosed to or intercepted by, unauthorized third parties. However, you may consent to receive email from us regarding your treatment. We will use the minimum necessary amount of protected health information in any communication. Our first email to you will verify the email address you provide.

I. Answer the following questions (Leave blank if you do not understand the question)
Is your general health good?
Has there been a change in your health within the last year?
Have you gone to the hospital or emergency room or had a serious illness in the last three years?
Are you being treated by a physician now?
Had problems with prior dental treatment?
Are you in pain now?
II. Have you experienced any of the following?
Chest Pain (Angina)
Fainting Spells
Recent Significant Weight Loss
Night Sweats
Persistent Cough
Coughing Up Blood
Bleeding Problems
Blood in Urine
Blood in Stools
Diarrhea or Constipation
Frequent Urination
Difficulty Urinating
Ringing in Ears
Blurred Vision
Bruise Easily
Frequent Vomiting
Dry Mouth
Excessive Thirst
Difficulty Swallowing
Swollen Ankles
Joint Pain or Stiffness
Shortness of Breath
Sinus Problems
III. Have you had or do you have any of the following?
Heart Disease
Family History of Heart Disease
Heart Attack
Artificial Joint
Stomach Problems or Ulcers
Heart Defects
Heart Murmurs
Rheumatic Fever
Skin Disease
Hardening of Arteries
High Blood Pressure
Cosmetic Surgery
Family History of Diabetes
Tumors or Cancer
Arthritis Rheumatism
Emphysema/Other Lung Disease
Kidney/Bladder Disease
Eating Disorders
Thyroid Disease
Sexual Transmitted Disease
Canker or Cold Sores
Liver Disease
Eye Disease
This information will not be released unless specifically authorized by patient.
Treatment for Emotional Condition
IV. Are you allergic to or have you had a reaction to any of the following?
Local Anesthetic
(Novocain or Xylocaine)
Nitrous Oxide
V. Are you taking or have you taken any of the following in the last three months?
Recreational Drugs
Over-the-Counter Medicines
Weight Loss Medications
Tobacco in any Form
Bisphosphonate (Fosamax)
VI. Women Only
Are you or could you be pregnant?
Are you nursing?
Are you taking birth control pills?
VII. All Patients
Do you have or have you had any other diseases or medical problems NOT listed on this form?
Have you ever been pre-medicated for dental treatment?
Have you ever taken Fen-Phen?
Is there any issue or condition that you would like to discuss with the dentist in private?

The practice of dentistry involves treating the whole person. If the dentist determines that there may be a potentially medically-compromised situation, medical consultation may be needed prior to commencement of dental treatment.
I authorize the dentist to contact my physician.

I certify that I have read and understand this form. To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication. Further, I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form.

Medical Updates

I have reviewed my Health History and confirm that it accurately states past and present conditions.