1 Page One2 Page Two3 Page Three4 Page Four5 Page Five Please fill out the form below. Contact Information Patient Title*- SELECT -Dr.Mr.Ms.Mrs.MissPatient First Name*Patient Last Name*Patient Name Preference*SSN*Patient Birthday* MM DD YYYY Patient Address*Apartment NumberCity*State*ZIP*Cell Phone*Home PhoneWork PhoneEmail* May we email you about appointments?*- SELECT -YesNoMay we email you with special offers?*- SELECT -YesNoMay we email you with general dental information?*- SELECT -YesNo Relationship InformationName of person responsible for accountOnly enter the name of the responsible party of different than the patient.Address/PhoneAddress/Phone for the responsible party (if different from before)Employer InformationIf patient/responsible party is employed, please name their employer. School NameIf patient/responsible party is a full-time student, please list the name of their school.Name of Spouse/PartnerIf patient/responsible party has a spouse/partner, please name them here.Spouse/Partner EmployerIf patient/responsible party has a spouse or partner, please list the employer of the spouse/partner here.Emergency Contact*Please name the patient's emergency contact here.Emergency Contact - Relationship*Please tell us the relationship of the patient's emergency contact.Emergency Contact - Phone*Please tell us the phone number of the patient's emergency contact.Nearest RelativePlease tell us the patient's nearest relative not living with them.Nearest Relative - RelationshipPlease tell us the relationship of patient's nearest relative not living with them.Nearest Relative - PhonePlease tell us the phone number of patient's nearest relative not living with them.How did you hear about our office?*- SELECT -www.BestDentalCareAZ.comPostcard / FlyerZocDocInternet Search (Google, Bing, etc.)Social Media (Facebook, Twitter, YoutTube, etc.)YelpTelevisionRadioNewspaper / MagazineWalk-In / Drive By / SignInsurance CompanyFestival / Community EventFriend / Co-Worker / FamilyThis websiteOtherPlease help us by telling us how you discovered our practice.If Friend / Co-Worker / Family, please tell us their name.If Insurance Company, please name the company.If Festival or Community Event, which one?If Other, where? Dental Insurance InformationDo you have dental insurance?*- SELECT -YesNoInsurance CompanyPlease name your insurance company.Insurance Phone NumberPolicy Effective Date MM DD YYYY Subscriber NameEmployerSSN or Member IDBirthdate MM DD YYYY Group # / Policy #RelationshipDo you have a secondary dental insurance?- SELECT -YesNoInsurance CompanyPlease name your insurance company.Secondary Insurance Phone NumberPolicy Effective Date MM DD YYYY Subscriber NameEmployerSSN or Member IDBirthdate MM DD YYYY Group # / Policy #Relationship Medical InformationAre you under the care of a physician now?*- SELECT -YesNoPhysician NamePhysician PhoneLast Physical Exam Do you currently have, or have you ever had any of the following?Heart Failure*- SELECT -YesNoHepatitis*- SELECT -YesNoNervousness / Depression*- SELECT -YesNoHeart Disease / Attack*- SELECT -YesNoLiver Disease*- SELECT -YesNoPsychiatric Treatment*- SELECT -YesNoChest Pain*- SELECT -YesNoEpilepsy or Seizures*- SELECT -YesNoMultiple Sclerosis*- SELECT -YesNoHigh Blood Pressure*- SELECT -YesNoFainting / Dizzy Spells*- SELECT -YesNoDiabetes*- SELECT -YesNoHeart Murmur*- SELECT -YesNoCancer / Leukemia*- SELECT -YesNoThyroid Disease*- SELECT -YesNoMitral Valve Prolapse*- SELECT -YesNoChemotherapy*- SELECT -YesNoHIV Positive*- SELECT -YesNoRheumatic Fever*- SELECT -YesNoGlaucoma*- SELECT -YesNoAIDS*- SELECT -YesNoHeart Defects*- SELECT -YesNoEmphysema*- SELECT -YesNoArthritis*- SELECT -YesNoScarlet Fever*- SELECT -YesNoAsthma*- SELECT -YesNoPain in Jaw Joints*- SELECT -YesNoArtificial Heart Valve*- SELECT -YesNoDifficulties Breathing*- SELECT -YesNoLoss of Appetite*- SELECT -YesNoHeart Pacemaker*- SELECT -YesNoSinus Trouble*- SELECT -YesNoLoss of Sleep*- SELECT -YesNoHeart Surgery*- SELECT -YesNoSevere Allergies / Hives*- SELECT -YesNoUse a C-pap*- SELECT -YesNoArtificial Joints / Prosthesis*- SELECT -YesNoYellow Jaundice*- SELECT -YesNoLoud Snoring*- SELECT -YesNoAnemia*- SELECT -YesNoDrug Addiction*- SELECT -YesNoBruise Easily*- SELECT -YesNoStroke*- SELECT -YesNoHemophilia*- SELECT -YesNo(Frequent) Cold Sores*- SELECT -YesNoKidney Disease*- SELECT -YesNoSickle Cell Disease*- SELECT -YesNoAdverse reaction to local anesthetic (Novacaine)*- SELECT -YesNoLatex Allergy*- SELECT -YesNoMedication AllergiesList any and all medications that you are knowingly allergic to, or have had an adverse reaction to.Current Medications*Please list ALL medications you are currently taking. If you are not taking any medications at this time, please type "none."Are you pregnant or trying to get pregnant?*- SELECT -YesNoAre you currently taking Birth Control Pills?*- SELECT -YesNoAre you currently taking Blood Thinners?*- SELECT -YesNoDo you smoke?*- SELECT -YesNoIs there any other medical information not included above which we should be informed about?- SELECT -YesNoAdditional Medical InformationBecause you answered "Yes" above, please tell us here.Have you ever or do you currently receive Botox® Injections?- SELECT -YesNoType of Botox® treatment.- SELECT -TherapeuticCosmeticBothPlease indicate the nature of your treatment.Dental InformationHas the fear of discomfort kept you from regular dental visits?*- SELECT -YesNoAre you satisfied with your past dentistry?*- SELECT -YesNoHave you had any bad experiences in a dental office?*- SELECT -YesNoHave you ever had Periodontal Therapy?*- SELECT -YesNoAre you concerned that you may have bad breath?*- SELECT -YesNoDo your gums bleed easily, feel tender or irritated?*- SELECT -YesNoAre your teeth sensitive to hot, cold and/or sweets?*- SELECT -YesNoAre there areas in your mouth where food sticks and/or gets caught?*- SELECT -YesNoAre you self-conscious about the appearance of your teeth?*- SELECT -YesNoDo your jaws often feel tired and/or sore?*- SELECT -YesNoDo you experience excessive headaches and/or neck pain?*- SELECT -YesNoDo you experience clicking or popping when opening/closing/chewing?*- SELECT -YesNoAre you aware of yourself clenching or grinding your teeth?*- SELECT -YesNoHave you ever had Orthodontic Treatment (Braces)?*- SELECT -YesNoWhat prompted you to seek dental care at this time?*Approximately how long has it been since your last dental examination & cleaning?*What, if anything would you do to change the appearance of your teeth? (Check all that apply) Whiter Straighter Longer Shorter Shaped Differently I would not change anything Consent I acknowledge that all of the above information is accurate to the best of my knowledge. I authorize this office and its trained staff to take x-rays & other diagnostic aids needed to make proper diagnosis of my dental needs. I authorize this office and its trained staff to perform all forms of treatment, as is indicated. I understand the use of anesthetic agents will be used when indicated & that this embodies a certain risk. I give my permission to release medical/dental information as needed to process insurance claim forms or to receive proper treatment from other health providers.Signature of Patient / Parent or Guardian*Entering your name above constitutes your signature to proceed.By entering my name above and checking this box, I consent to give this information.* I consent. Financial Agreement FINANCIAL AGREEMENT Payment in full for all charges is required at time of visit, unless prior arrangements have been made. INSURANCE FILING You, the patient, are ultimately responsible for payment in full on your account, not the insurance company. We do, however, file dental insurance claims as a courtesy to our patients. We can only make estimates regarding your insurance benefits based on the information provided by you and the insurance company. In the event your insurance company does not pay as much as expected, the remaining balance is due and payable immediately by you, the patient. ASSIGNMENT OF INSURANCE BENEFITS I/we hereby assign directly to Pleasant Dentistry Westbrook hereby authorize the release of any information relating to any claims. I/we understand I/we are financially responsible for charges not paid by this assignment.I agree to the terms listed above.* Yes, I agree to the terms listed above. By checking this box you agree to the terms listed above.DELINQUENT ACCOUNTS All delinquent accounts (30 days or older) are subject to reasonable service charges and/or legal interest rates. COLLECTION PROCEEDINGS In the event your account is turned over to a collection agency for non-payment or other delinquency, you will be responsible for payment of any and all reasonable collection costs and/or attorney fees, in addition to the balance owed. Any account turned over to a collection agency forfeits any past special fees and/or discounts. Such special fees and/or discounts will be reversed and you will be responsible for payment of regular fee for procedures at the time of service. FAILED APPOINTMENTS Failed appointments (less than 24 hours notice) are a significant contributor to rising heath care costs. Individuals who fail to show for a confirmed appointment will be assessed a fee based on the length of the missed appointment.I agree to the terms listed above.* Yes, I agree to the terms listed above. By checking this box you agree to the terms listed above.ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I have received a copy of this office's Notice of Privacy Practices. I understand that I have a right to refuse to sign this acknowledgment.I agree to the terms listed above.* Yes, I agree to the terms listed above. By checking this box you agree to the terms listed above.FOR MEDICARE ELIGIBLE PATIENTS ONLY I understand that this office is a non-participating office with Medicare. I further understand that as a nonparticipating provider, Pleasant Dentistry Westbrook will not submit insurance claims to Medicare on my behalf. I understand that neither Medicare’s fee limitations nor any other Medicare reimbursement regulations apply to services provided by Pleasant Dentistry Westbrook.I agree to the terms listed above.* Yes, I agree to the terms listed above. I do not use medicare. By checking this box you agree to the terms listed above.Signature of Patient / Parent or Guardian*Entering your name above constitutes your signature to proceed.PhoneThis field is for validation purposes and should be left unchanged.