Adult New Patient Form

General Information

First Name*

Middle

Last Name*

I prefer to be called

DOB*

Home #

Cell #

Work #

Ext #

Home Address*

City*

State*

Zip*

Email Address*

Social Security #*

Employer

Human Resource #

Employer Address

City

State

Zip

Gender*

Pronoun

Marital Status

Spouses Name

Spouse DOB

Spouse Employed By

Spouse Social Security #

Whom may we thank for referring you to us?*

Website
Phone Book
TV
Family/Friend
Other

If other:

Responsible Party Information

Name of Responsible Party

Relationship to Patient

DOB

Phone #

Address

City

State

Zip

Insurance Information

Primary Insurance

Name of Insured

Employer

Social Security #

Name of Dental Insurance Co.

Group #

Address to send claims to

Secondary Insurance

Name of Insured

Employer

Social Security #

Name of Dental Insurance Co.

Group #

Address to send claims to

Health History Questionnaire

All questions contained in this questionnaire are strictly confidential and will become part of your medical record.

Dental History

Name of Previous Dentist

Date of last dental visit?*

0-6 Months
6-12 Months
12-24 Months
greater than 24 months

Date of last x-rays?*

0-6 Months
6-12 Months
12-24 Months
greater than 24 months

How often do you floss?*

How often do you brush?*

Do any apply to you?

Health History

Name of previous Physician

Date of last physical exam?*

0-6 Months
6-12 Months
12-24 Months
greater than 24 months

Height

Weight

Do you smoke or use tobacco?*

Yes
No

How long?

If female, please answer the following

Are you taking birth control pills?

Yes
No

Are you pregnant?

Yes
No

How many weeks?

Are you nursing?

Yes
No

Allergies to medications

Are you allergic to any of the following?*

Other allergies

Check if you have, or have had symptoms in the following areas to a significant degre*

Other Conditions

Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment.

List all medications, supplements, and/or vitamins taken within the last two years.

Drug

Dosage

Drug

Dosage

Drug

Dosage

Drug

Dosage

I understand and agree that, regardless of my insurance status, I am ultimately responsible for the balance on my account for any services rendered. I certify that this information is true and correct to the best of my knowledge. I will notify you of any changes in my health status or the information provided.

Patient's Signature*

Date*

Social Media & Website Consent Form

First of all, thank you! Thank you for selecting Gentle Dentistry. We would love to post your review, picture, and experience here online at www.gentledentistrykzoo.com, within our website. If you would like to take part in recognizing our office online within our patient section, homepage, or testimonial on our website, Facebook, or Twitter, please sign below. This form states that you freely give consent to take part in our website, and authorize that your first name and only initial of your last name can be publicly displayed within Gentle Dentistry's website. You understand that by signing this form you are agreeing to take part in our online media source(s) and website. You have received a copy of this form to take with you, as well. We, the staff here at Gentle Dentistry, thank you. We were happy to have you as a patient here for all your dental health care needs.

Patient's Signature

Witness Statement

I confirm that I was present for the verbal and written statement summary presented to the patient mentioned above, as well as the execution of this form. I agree that the information was accurately explained to, and apparently understood by, and that informed consent was freely given by the patient.

Signature of Witness

Written Financial Policy

Thank you for choosing Gentle Dentistry. Our primary mission is to enable our patients to achieve excellence in oral health and freedom from head and neck pain. We will make every effort to provide quality dentistry in a caring and professional atmosphere.

Payment Options

Full payment is expected at the time of service. You may choose from:

Cash, check, credit card (Visa, MasterCard, Discover, and American Express), debit card, HSA, FSA
Payment Plans from CareCredit

Insurance

We may accept assignment of insurance benefits providing all paperwork and necessary information is complete. We do require that deductibles and co-payments be paid at the time of service. Your insurance policy is a contract between you, your employer, and the insurance company. You, the patient, have the ultimate financial responsibility for treatment. If any services are rejected by your insurance, you are responsible for the fees. If we do not receive payment from your insurance carrier within 30 days, you will be responsible for payment of your treatment fees and collection of your benefits from your insurance carrier. Accounts not paid within 30 days are subject to a monthly statement fee and may be recovered through a collection agency.

All levels of payment by insurance companies, including allowed fees, usual and customary (UCR), are governed by the premiums paid. The payments have nothing to do with the actual charges. The treatment recommended by our office is never based on what your insurance company will pay but what your dental health needs are. Your treatment should not be governed by your insurance contract.

Please take the time to review your insurance contract thoroughly so we may best serve you and help you to receive the maximum benefits toward your dental health. As always, you may feel free to ask any member of our team for clarification on services, billing, and insurance.

Cancellation Policy

We would greatly appreciate a 48-hour notice from any patient (or patient representative) should they need to reschedule or cancel an appointment. We reserve the right to apply a cancellation fee if this policy is not respected.

If you have any questions, please do not hesitate to ask. We are here to help you get the dentistry you need or want.

I have read this policy and agree to it.

Signature*

Date*

HIPPA OMNIBUS RULE

PATIENT ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND CONSENT/LIMITED AUTHORIZATION & RELEASE FORM

You may refuse to sign this acknowledgment & authorization. In refusing we may not be allowed to process your insurance claims.

Date*

The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original.

MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR/FACILITIES IN THE FUTURE.

Please print name of Patient*

Please sign for Patient/Guardian of Patient*

Legal Representative/Guardian*

Relationship of Legal Representative/Guardian*

Your comments regarding Acknowledgements or Consents

HOW DO YOU WANT TO BE ADDRESSED WHEN SUMMONED FROM THE RECEPTION AREA*

First Name Only
Proper Surname

Other:

PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION:

(This includes step-parents, grandparents and any caretakers who can have access to the this patient's records):

Name

Relationship

Name

Relationship

I AUTHORIZE CONTACT FROM THIS OFFICE TO CONFIRM MY APPOINTMENTS, TREATMENTS & BILLING INFORMATION VIA*

Cell Phone Confirmation
Home Phone Confirmation
Work Phone Confirmation
Text Message to my Cell Phone
Email Confirmation
Any of the Above

I AUTHORIZE INFORMATION ABOUT MY HEALTH BE CONVEYED VIA*

Cell Phone Confirmation
Home Phone Confirmation
Work Phone Confirmation
Text Message to my Cell Phone
Email Confirmation
Any of the Above

I APPROVE BEING CONTACTED ABOUT SPECIAL SERVICES, EVENTS, FUND RAISING EFFORTS or NEW HEALTH INFO on behalf of this Healthcare facility via:*

Phone Message
Text Message
Email
Any of the Above
None of the above (opt out)

In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or services to promote your improved health. This office may or may not receive third-party remuneration from these affiliated companies. We, under current HIPAA Omnibus Rule, provide you with this information with your knowledge and consent.

Signature*

Office Use Only

As Privacy Officer, I attempted to obtain the patient's (or representative's) signature on this Acknowledgement but did not because:

It was emergency treatment

Yes
No

I could not communicate with the patient

Yes
No

The patient refused to sign

Yes
No

The patient was unable to sign because ________________

Yes
No

Other (please describe) _________________________________

Yes
No

Signature of Privacy Officer

CAPTCHA

Phone

This field is for validation purposes and should be left unchanged.

Dentist In Kalamazoo, MI

General Information

Responsible Party Information

Insurance Information

Primary Insurance

Secondary Insurance

Health History Questionnaire

Dental History

Health History

Allergies to medications

Social Media & Website Consent Form

Witness Statement

Written Financial Policy

Payment Options

Insurance

Cancellation Policy

I have read this policy and agree to it.

HIPPA OMNIBUS RULE

PATIENT ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND CONSENT/LIMITED AUTHORIZATION & RELEASE FORM

MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR/FACILITIES IN THE FUTURE.

Office Use Only

Emergency Dental Care