Adult New Patient Form About YouToday's Date: MM slash DD slash YYYY E-mail Address: Name First Last Name I prefer to be called:Birthdate: MM slash DD slash YYYY Gender: Male Female SS#Home Address: Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mailing Address: Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone:Cell:Work:Whom may we thank for referring you?Other family members seen by us:Employer:How long there?Occupation:Marital Status:SingleMarriedDivorcedMinorSpouse Information (if patient is a minor)Name: First Last Birthdate: MM slash DD slash YYYY Age:Gender: Male Female SS#Home Phone:Cell:Work:Employer:How long there?Occupation:Emergency Contact InformationName:Relationship:Home Phone:Cell:Work:Insurance InformationPrimary Insurance Yes, primary insurance applies to me No, primary insurance does not apply to me Primary Dental Insurance:Address: Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone:Subscriber:Subscriber ID#:Subscriber Date of Birth: MM slash DD slash YYYY Subscriber relation to the patient:Secondary Insurance Yes, secondary insurance applies to me No, secondary insurance does not apply to me Secondary Dental Insurance:Address: Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone:Subscriber:Subscriber ID#:Subscriber Date of Birth: MM slash DD slash YYYY Subscriber relation to the patient:I hereby authorize any associate of Gifford Family Dentistry to release any and all dental information to process my insurance claim. I hereby authorize my insurance company to pay directly to Gifford Family Dentistry all dental benefits due me, by reason of dental services rendered. I understand I am financially responsible to the dentist for charges not covered by this authorization.SIGNATURE OF PATIENT (or guardian)Date: MM slash DD slash YYYY Financial Policy Thank you for choosing Gifford Family Dentistry. Our team takes pride in providing every patient with the best possible dental care. We want you to feel as comfortable as possible throughout your treatment. This includes understanding your treatment plan as well as our financial policy. Do You Accept My Insurance? How Much Will They Pay?We currently work with most private dental benefit plans. The amount of coverage that your benefit plan provides is negotiated between your employer and the insurance company. Payment of benefits for provided treatment is never guaranteed by the insurance companies. Therefore, it is impossible to give you a guaranteed quote prior to or at the time of service, even if the services are preauthorized. We estimate your portion based on the most upto- date information we have, but it is still only an estimate. We will always make a diligent effort to collect the full portion due from your insurance company. We accept and bill your insurance claiming assignment of benefits. What this means is your insurance will pay our office directly and we will apply it to your claim accordingly. If your insurance does not accept assignment of benefits and pays you directly, it is your obligation to forward that payment to our office to assign their portion of the claim.PATIENT INITIALS:My Insurance Did Not Pay Now What?Please keep in mind that a dental benefit plan is a contract between you, your employer, and the insurance company. We will bill your insurance company as a courtesy to you; however, while we will attempt to help you understand your plan, it is your obligation to know your insurance plan, exclusions, limitations, and ultimately pay for any treatment your insurance company refuses to cover.PATIENT INITIALS:Minor PatientsThe adult(s) accompanying a minor and the parent(s) (or guardians of the minor) are responsible for full payment. For unaccompanied minors, non-emergency treatment will be denied unless charges have been pre-authorized to an approved credit plan, credit card, or payment by cash or check at the time the service has been verified. In the case of pending divorce or separation, the party responsible for the account prior to the divorce or separation remains the responsible party. After a divorce or separation, the parent authorizing the treatment for a child will be the parent responsible for those subsequent charges. If the divorce decree requires the other parent to pay all or part of the treatment costs, it is the authorizing parent’s responsibility to collect from the other parent. We are unable to place a parent or guardian on an account, as the responsible party, without the express, written authorization from that parent.PATIENT INITIALS:Financial ResponsibilityYour estimated portion is due at the time of service. We accept cash, checks, Visa, MasterCard, and Care Credit. Finance Charges: All severely past due balances (60 days and greater) are subject to finance charges of 12% APR, or a minimum of $5 per month. This is to offset the costs associated with repeated billing of statements. Late Arrivals and Broken Appointments: Please give us a courtesy call if you are running late. We trust that our patients make every effort to honor the day and time reserved for them, and we strive to run on time out of respect for every patient on the schedule. Late arrivals and broken appointments harm a dental practice’s ability to be successful. Please provide at least 2 business days advance notice if you want to reschedule your reserved time. Our business days consist of Tues-Fri. A $150 fee may be charged for appointments missed or broken with less than 2 business days advance notice. Extenuating circumstances are considered. Repeat offenses may result in dismissal.I am financially responsible for all charges. If it becomes necessary to effect collections of any amount owed on this or subsequent visits, I agree to pay for all costs and expenses, including reasonable attorney fees. I hereby authorize the doctor to release information necessary to secure payment.PATIENT INITIALS:Patient Name:Date MM slash DD slash YYYY SIGNATURENAME OF RESPONSIBLE PARTY:Medical HistoryPhysician’s Name:Address/Clinic: Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone #:Date of last visit: MM slash DD slash YYYY Your current physical health is: Good Fair Poor Are you currently under the care of a physician? Yes No Please explain:Do you use alcohol? Yes No Do you smoke or use tobacco in any other form? Yes No Have you ever taken Fosamax or any other medication for bone preservation? Yes No For Women: Are you taking birth control pills? Yes No Are you pregnant? Unsure Yes No Week#Are you nursing? Yes No Please check all conditions that you do have or have experienced in the past Heart Problems / Surgery Low Blood Pressure Asthma, Emphysema Disorder Persistent Cough Tuberculosis Ulcers Colitis or Irritable Bowel Blood Transfusion Rheumatic/Scarlet Fever Congenital Heart Defects Pacemaker Hepatitis ( A, B, or C ) Kidney Problems Stroke Depression Dizzy or Fainting Spells Hay Fever Shingles Diabetes ( I / II ) Liver Problems Anxiety Psychiatric Problems Artificial Bones/Joints Cancer HIV/AIDS Herpes/Fever Blister Sinus Problems Epilepsy/Seizures Headaches Lupus Arthritis Drug Abuse Glaucoma Thyroid Problems Radiation/Chemotherapy Hospitalized for any reason Sexually Transmitted Disease High Blood Pressure Abnormal Bleeding Anemia Endocarditis Artificial Heart Valve Please list any serious medical condition(s) that you have experienced:Please list all prescription/over the counter drugs, blood thinners or heart medications you are taking or have taken in the last 30 days:Are you allergic to any of the following? Please check all that apply Aspirin Dental Anesthetics Codeine Jewelry / Metals Erythromycin Penicillin Latex Sulfa Drugs Sedatives Other Tetracycline Barbiturates Please list anything additional that causes allergic reactions:Authorization I affirm that the information I have given is correct to the best of my knowledge, and that it is my responsibility to inform this office of any changes in my medical status.Patient Name:Parent or Guardian SignatureDate MM slash DD slash YYYY Parent SignatureDate MM slash DD slash YYYY Medical History Update I have read my medical history and confirmed that it states past and present medical conditionSignature:Date MM slash DD slash YYYY Dental HistoryWhy have you come to the dentist today?Are you currently in pain? Yes No Have you ever required antibiotics before dental treatment? Yes No Your current dental health is: . Good Fair Poor Do you floss daily? Yes No Brush daily? Yes No Type of toothbrush? Manual Battery Electric Sonic Are you satisfied with the appearance of your smile? Yes No If No, what would you like to change: (check those that apply) Length of teeth color spaces crowding other Have you ever had any serious complications with prior dental treatment? Yes No What?Have you had any head, neck or jaw injuries? Yes No Do you have frequent headaches? Yes No Do your gums ever bleed? Yes No Have you ever had periodontal disease? Yes No Are your teeth sensitive to heat, cold, or anything else?Have you ever had periodontal disease? Yes No Previous / Present DentistDate Last Visit Date MM slash DD slash YYYY Why did you leave your last dentist?Have you ever experienced any of the following problems in your jaw? Clicking? Yes No Pain (joint, ear, side of face)? Yes No Difficulty in opening or closing? Yes No Difficulty in chewing? Yes No Do you clench or grind your teeth? Yes No Have you had any orthodontic work (braces)? Yes No Have you ever whitened your teeth? Yes No COMFORT QUESTIONNAIRE For each of these questions, select the number under the word or phrase that best describes your feelings.If you had to go to the dentist tomorrow, how would you feel about it?Very RelaxedA Little UneasyTenseAnxiousImagine you are waiting in the dentist’s office for your turn in the chair. How do you feel?Very RelaxedA Little UneasyTenseAnxiousImagine you are sitting in the dentist’s chair as she prepares to give you a shot. How do you feel?Very RelaxedA Little UneasyTenseAnxiousImagine you are sitting in the dentist’s chair as she prepares the drill to work on your teeth. How do you feel?Very RelaxedA Little UneasyTenseAnxiousImagine you are waiting in the hygienist’s chair and he/she is getting the instruments used to scrape your teeth. How do you feel?Very RelaxedA Little UneasyTenseAnxiousCONSENT The undersigned hereby authorizes the doctor to take radiographs, study models, photographs, or any other diagnostic aids deemed appropriate to make a thorough diagnosis of the patient’s dental needs. I also authorize the doctor to perform any and all forms of treatment, medication and therapy that may be indicated in connection with the patient and further authorize and consent that the doctor choose and employ such assistance as he deems fit. I understand that the use of anesthetic agents and certain treatments embody some risk. In good faith, the doctor I hereby give my permission to Gifford Family Dentistry to release my dental records to my insurance company, specialists I may be referred to or others to whom I may request my records be sent. I understand that responsibility for payment for dental services provided in the office for myself and/or my dependents is mine and not my insurance company, my employer or any other third party. Arrangements for payment will be made before initial treatment begins. Breach of this responsibility carries the penalty of compensating the doctor(s) for attorney’s and collection fees. I understand that, where appropriate, credit bureau reports may be obtained. I agree and understand that any and all legal disputes related to the services of Gifford Family Dentistry or affiliates shall be determined by submitting to binding arbitration.Do you have dental records at another practice ?* Yes No Patient Name:Date MM slash DD slash YYYY SIGNATURE OF PATIENT (or guardian)Consent* By submitting this form, I agree to receive marketing messages, including special offers, updates, and news, and understand I can change my preferences at any time. 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