Patient Forms Patient FormsNew Patient FormPlease take a few minutes to answer the following questions so we can better assist you with your dental needs. Please list N/A for any fields that do not apply.First Name:Middle Initial:Last Name:Date:Social Security #:Birthdate:Home Phone:Cell Phone:Email:Street Address:Apt, Suite, Unit, etc. (optional):City:State:Zip Code:Sex: Male Female OtherIf other, please list below:Relationship: Minor Single Married OtherIf other, please list below:Employer:Occupation:Business Phone:Business Street Address:Business Apt, Suite, Unit, etc. (optional):City:State:Zip Code: In case of emergency, who should we contact:Emergency Contact First Name:Emergency Contact Last Name:Emergency Contact Phone:Relationship to Emergency Contact:Primary InsurancePerson Responsible for Account:Relationship to Patient:Birthdate:Social Security #:Home Phone:Street Address:Apt, Suite, Unit, etc. (optional):City:State:Zip Code:Responsible Party Employed By:Occupation:Business Phone:Business Street Address:Business Apt, Suite, Unit, etc. (optional):City:State:Zip Code:Insurance Company:Insurance Company Street Address:Insurance Company Apt, Suite, Unit, etc. (optional):City:State:Zip Code:Subscriber I.D. #:Group #:Additional InsuranceInsured First Name:Insured Last Name:Relationship to Patient:Birthdate:Social Security #:Home Phone:Additional Street Address:Additional Apt, Suite, Unit, etc. (optional):City:State:Zip Code:Insured Party Employed By:Occupation:Business Phone:Insurance Company Street Address:Insurance Company Apt, Suite, Unit, etc. (optional):City:State:Zip Code:Subscriber I.D. #:Group #:Dental HistoryFormer Dentist:City:State:Date of Last X-Rays:Date of Last Dental Visit:How Often Do You Floss:How Often Do You Brush:Please Check All That Apply: Bad Breath Bleeding Gums Blisters on Lips or Mouth Finger Nail Biting Grinding Teeth Lip or Cheek Biting Loose Teeth or Broken Fillings Orthodontic Treatment Pain Around Ear Periodontal Treatment Sensitivity to Cold Sensitivity to Heat Sensitivity to Sweets Sensitivity When Biting Frequent Headaches Jaw, Head or Neck Injuries Jaw Difficulty: Clicking and/or Pain Tooth PainMedical HistoryFirst Name:Last Name:Date of Last Visit:1. Are you currently under medical treatment? Yes No2. Have you ever had any serious illness or operations? Yes No3. Are you currently taking any medication? Yes NoIf yes, please list:4. Do you smoke? Yes No5. Do you use alcohol, cocaine, or any other drugs? Yes No6. Do you wear contact lenses? Yes No5. Do you use alcohol, cocaine, or any other drugs? Yes No7. Have you had any allergic reactions to the following: Local Anesthetics (eg. novacaine) Penicillin or other Antibiotics Sulfa Drugs Barbiturates (sleeping pills) Sedatives Iodine Aspirin OtherIf you selected other, please list:8. (Women Only) Are You: Pregnant Nursing Taking Birth Control PillsPlease Check All That Apply: AIDS Anemia Arthritis, Rheumatism Artificial Heart Valves Artificial Joints Asthma Back Problems Bleeding abnormally with extractions or surgery Blood Disease Cancer Chemical Dependency Chemotherapy Chronic Fatigue Syndrome Circulatory Problems Congenital Heart Lesions Cortisone Treatments Cough-Persistent or Bloody Diabetes Emphysema Epilepsy Fainting or Dizziness Glaucoma Headaches Heart Murmur Heart Problems Hepatitis-Type (list type below) Herpes High Blood Pressure HIV Positive Jaundice Jaw Pain Kidney Disease Latex Sensitivity Liver Disease Low Blood Pressure Mitral Valve Prolapse Nervous Problems Pacemaker Psychiatric Care Radiation Treatment Respiratory Disease Rheumatic Fever Scarlet Fever Shortness of Breath Sinus Problems Skin Rash Stroke Swelling of Feet/Ankles Swollen Neck Glands Thyroid Problems Tonsillitis Tuberculosis Tumor or growth on head/neck Ulcer Venereal DiseaseIf you selected Hepatitis-Type Herpes, please list your type below:Assignment and ReleaseI hereby authorize payment directly to Mindy Fugett, DMD for all insurance benefits otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, whether or not paid by insurance, and for all services rendered on my behalf or my dependents. I authorize the above doctor and/or any provider or supplier of services in this office to release the information required to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.Signature of Responsible Party Sign Here HIPAA PrivacyI understand that according to the Federal HIPAA law that this office is unable to discuss my treatment, account balance or any other matters pertaining to me unless I indicate that they may do so. I agree that the following people can be informed of any association that I may have with this office including, but not limited to treatment, diagnosis, financial agreements, account balances and my general well-being. Please List:1.2.3.This consent applies until I ask that the name be deleted and a new form replaces this one. I certify that I have received a copy of the Join Notice of Privacy provided by Dr. Mindy’s Family Dentistry.Patient Signature Sign Here Patient DatePractice Representative Sign Here Representative DateRecords ReleasePatient First NamePatient Last NameDateDate of BirthEmailPlease release all my dental x-rays to:My signature below gives consent to do so.Patient Signature Sign Here Patient DateImportant Insurance MessageToday, most insurance companies require that the patient be aware of the particulars of his/her insurance coverage. Further, the patient must fulfill certain requirements prior to being seen by a dentist. Your failure to comply may result in reduced payment or denial of your entire claim. PLEASE READ THE FOLLOWING CAREFULLY BEFORE SIGNING BELOW I have been advised that if services rendered by Dr. Mindy's Family Dentistry are considered to be "non-covered services" by my insurance company, I will be financially responsible. I have been advised that if Dr. Mindy's Family Dentistry is not a contracted provider for my insurance company, I will be financially responsible for any and all charges rendered to me. I have been advised that if I do not provide complete insurance information prior to my visit, Dr. Mindy's Family Dentistry cannot file a claim until all information is given and gathered. If I elect to receive care under these circumstances, I understand that I will be financially responsible for any and all charges for services rendered until coverage for such services can be verified. Patient Signature Sign Here Patient DatePatient First NamePatient Middle InitialPatient Last NameSUBMIT FORM Please contact us if you have any questions or need any assistance with filling out our Patient Forms. Call for Assistance!
