New Patient Forms Step 1 of 5 20% X/TwitterThis field is for validation purposes and should be left unchanged.Name First Middle Initial Last Nickname Address Street Address Address Line 2 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 EmployerBirthdateMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SSNHeightWeightHome PhoneMobile PhoneWork PhoneMay we contact you at work? Yes No Gender Male Female Marital Status Married Single Dependent/Child Please select your preferred contact method for appointment confirmations: Phone call Text message Please select your preferred contact method for recall appointments: Phone call Text message Postcard Emergency Contact NameEmergency Contact Phone NumberEmergency Contact Relationship to Patient Insurance (complete section only if you have dental insurance) Primary Dental Carrier Subscriber NameSubscriber SSNSubscriber BirthdateMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Subscriber EmployerInsurance Co.Insurance Co. PhoneGroup #Relation to PatientI hereby authorize payment directly to the dental office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all cost and dental treatment.SignatureYour NameYour NameYour NameYour NameDate Month Day Year If Patient is under 18:Responsible PartyRelation to PatientAddress Street Address Address Line 2 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 Medical History and InformationYour current health is: Good Fair Poor Are you currently in pain? Yes No Have you ever had gum treatment? Yes No Do your gums bleed? Yes No Are you under stress (new job, moving, relationships)? Yes No How many times do you floss each week?How many times do you brush each day?Are your teeth sensitive to hot, cold or anything else? Yes No Have you lost any teeth? Yes No Do you take any bone density medications? Yes No Do you suffer from aphthous ulcers or fever blisters? Yes No If so, we have a therapeutic laser procedure that can alleviate the pain and future reoccurrence of these lesions at the treated sites.Please list your personal physician and phone number:Please list any medical specialist(s) and phone number(s) whose care you are presently under:Please list any surgical procedures you have had in the last 5 years:Have you had any metal rods, pins, prosthetics, screws, or implants placed? Yes No ConditionsPlease check all that apply: Abnormal Bleeding Alcohol Abuse Allergies Anemia Angina Pectoris Arthritis Artificial Heart Valve Asthma Birth Control Pills Blood Transfusion Cancer Chemotherapy Colitis Congenital Heart Defect Diabetes Difficulty Breathing Drug Abuse Emphysema Epilepsy Facial Surgery Facial Trauma Fainting Spells Fever Blisters Frequent Headaches Glaucoma HIV+/AIDS Heart Attack Heart Surgery Heart Murmur Hemophilia Hepatitis A Hepatitis B Hepatitis C High Blood Pressure Joint Replacement Kidney Problems Liver Disease Low Blood Pressure Mitral Valve Prolapse Pacemaker Psychiatric Problems Radiation Therapy Rheumatic Fever Seizures STD's Shingles Sickle Cell Disease Sinus Problems Stroke Thyroid Problems Tuberculosis Vertigo Allergies Aspirin Codeine Sedatives Dental Anesthetics Erythromycin Latex Metals Penicillin Sulfa Tetracycline Other AllergiesDo you suffer from any other conditions/disorders that are not listed above?Please list any medications that you are currently taking:Tobacco/Dip? Yes No Do you usually pre-med before your dental visits? Yes No If Female: Are you pregnant? Yes No Are you nursing? Yes No I attest that the information given is true and accurate to the best of my knowledge.SignatureYour NameYour NameYour NameYour NameDate Month Day Year Other InformationHow did you hear about us? Mailer Sign/Drive by Internet/Google Internet/Yahoo Yellow Pages Phonebook AT&T Phonebook Pelican Pages Phonebook Friend/Referral Other If Friend/Referral or Other, please list:What is the reason for today’s visit?Would you be interested in the use of Nitrous Oxide to make your visits easier? Yes No Why did you leave your last dentist?What did you like most about your last dentist?Have you had any unfavorable dental experiences? Yes No When was your last dental cleaning?When was your last dental x-ray?When was your last dental visit?How can we accommodate you better during your dental visit?Do you love your smile?Here at Main Street Dental Care, we offer a wide variety of services to enhance and keep your smile beautiful. Please select any services below that you would like our friendly staff to discuss with you during your visit. In-Office Whitening Veneers Implants/Implant Crowns Botox Take Home Whitening Crowns and Bridges Smile Makeover 6 Month Braces (Orthodontics) Partials/Dentures Sealants Invisalign Bonding Night/Sport Guard Treatment Authorization Form I authorize and give consent to perform dental services agreed between doctor and patient are/or parent or guardian to be necessary or advisable including the use of local anesthesia and other medications as indicated. I certify to the above statements regarding my medical condition. Payment for all treatment and services rendered are my responsibility.Patient's SignatureYour NameYour NameYour NameYour NameDate Month Day Year Parent/Guardian SignatureYour NameYour NameYour NameYour NameDate Month Day Year FINANCIAL AND INSURANCE ACKNOWLEDGEMENT At Main Street Dental Care, we believe that you deserve the best care. That is why we always present you with the best dental solution possible to treat your personal situation. Each year we provide outstanding dental care to hundreds of patients. Some have dental benefits, but some do not. If you have dental benefits, congratulations! You are very fortunate. Here are some important things you should know: Your dental benefits are based on a contract made between your employer and an insurance company. If you have any questions regarding your dental benefits, please contact your employer or insurance company directly. Dental benefit plans will never pay for completion of your dental care. It is only meant to assist you. We currently accept all private care insurance plans (plans that do not require you to select a dentist from a list or require our office to accept a reduced fee for service). This means that we work with literally thousands of companies. Although we can maintain computerized histories of payment by a given company, they do change; therefore, it is impossible to give you a guaranteed quote at the time of service. We estimate your portion based on the most up-to-date information we have, but it is ONLY AN ESTIMATE. If you would like to know your exact insurance benefit, we will be happy to file a "pre-treatment authorization" with your insurance company prior to treatment. This does delay treatment but will give you the exact out of pocket figures you may require. Many people receive notification from their insurance company that dental fees are "above usual and customary." An insurance company determines their reimbursement level by surveying a geographical area, calculating the average fee, and then determines that 80% of the average fee is customary. Included in this survey are discounted dental clinics and managed care facilities, which have severely reduced dental fees that bring down the average. Any doctor in private practice will have fees that insurance companies define as "higher than usual and customary." We bill your insurance as a courtesy. If insurance does not pay within 90 days, Main Street Dental Care reserves the right to request payment in full for services from you and let you collect the insurance funds that are due to you. This is rare, but it is important that you recognize that the insurance you have is a legal contract between YOU and your insurance company. Our office is not and cannot be a part of that legal contract. Ultimately, you are responsible for all charges incurred in our office. Main Street Dental Care does require payment in full for your portion at the time of service. We accept MasterCard, Visa, Discover, cash and checks (for existing patients with established payment history). We do not accept checks for over $500.00 for any patient. If you are in need of an extended finance option, we also work with Care Credit, who offers a twelve month "same as cash" or longer terms with an interest-bearing revolving charge designed to meet your treatment plan needs on approved credit. Just ask one of the patient services staffs for an application. A $25.00 fee will be added to your account balance for any returned checks due to insufficient funds, as well as the amount of the returned check. Office Refund Policy If your account results in a credit due to write offs within two years' time, you are not eligible for a refund check. Our office will however allow you to use that credit toward future work. Broken Appointments A specific amount of time is reserved especially for you and we strongly encourage all patients to keep their appointments. If you must change your appointment, we require at least 24-hour notice to avoid a $35/hour cancellation fee (emergencies are an exception). After Hours/Weekend Emergencies In the event of an emergency after regular business hours a $55 emergency fee will be charged for established patients in addition to the necessary treatment fees. Patients who are not established in the practice will be charged $125 after hours emergency fee. We welcome you to our family and look forward to helping you get the healthy, beautiful smile that you have always wanted. If there is anything we can do to make your visits here more pleasant, please don't hesitate to ask one of our staff members.SignatureYour NameYour NameYour NameYour NameDate Month Day Year CONSENT FOR DENTAL TREATMENT AND ACKNOWLEDGEMENT OF RECEIPT OF INFORMATION State law requires us to obtain your consent for dental treatment. Please ask us about anything you do not understand. We are ready to answer any of your questions or explain anything you do not understand. There are risks associated with any dental treatment. This includes the administration of any local or general anesthetic agent, analgesic agent(s) to produce conscious sedation and/or premedication prior to dental care being rendered. Some of these risks/complications are, but are not limited to the following: Infection Bleeding Failure of wound to heal Loss of teeth Loss of bone Instrument breakage Bacterial endocarditis Breakage of root(s) and retained root fragments Swallowing and/or aspiration of objects Failure of treatment to accomplish main purpose Trismus (jaw pain or difficulty opening mouth) Opening between mouth and sinus or mouth and nose Injuries to adjacent teeth and/or hard/soft tissue Dry socket Incomplete removal of tooth Injury to adjacent structures Allergic reaction to drugs Tooth or fragment in maxillary sinus Death (in rare instances) Paresthesia or numbness of tongue and/or mouth, and/or face Fracture of mandible (lower jaw) or maxilla (upper jaw) Slough (unanticipated loss of hard and/or soft tissue) Additional oral surgery, hospitalization and/or further treatment may be required in the event of any complication(s). ACKNOWLEDGEMENT I acknowledge that I have read this consent form, or that it has been read to me, and that I understand the information contained on this consent form. I was given an adequate opportunity to ask any questions and all questions were answered to my satisfaction. I hereby authorize and direct the dentist and/or associates, hygienist, assistants of their choice to perform the diagnostic, surgical or dental treatment. This consent form will remain valid unless revoked by me in writing.Signature of patient or guardianYour NameYour NameYour NameYour NameDate Month Day Year NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT I understand that, under the Health Insurance Portability & Accountability Act of 1996 ("HIPPA"), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly. Obtain payment from third-party payers. Conduct normal healthcare operations such as quality assessments and physician certifications. I have received, read, and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization had the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or healthcare operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.Patient Name:Relationship to Patient:(If patient is a minor)SignatureYour NameYour NameYour NameYour NameDate Month Day Year Please list any individual(s) that you give permission to have access to records (medical & financial):
