New Patient Form

Step 1 of 7 - New Patient Information

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Date

Whom may we thank for referring you to our office?

Name(Required)

First Last

CA Driver License Number

Age

Please enter a number less than or equal to 110.

Home Phone

Cell Phone

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Social Security #

Birth Date(Required)

Marital Status

Employer's Name

Do you have insurance?(Required)

Yes

I'm not sure

If yes, insurance company name

Insurance Member ID

Insurance Group Number

Second Insurance Name

Spouse or Responsible Party Name

Home Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Social Security Number

Birthday

Marital Status

Employer's Name

Occupation

Work Phone

Is anyone else in your immediate family a patient in this office?

Yes

If yes, who?

Name of person to call in case of an emergency

First Last

Emergency Contact Phone Number

Name of Family Physician

Family Physician Phone Number

Potential Risks and Limitations Of Dental Treatment

As a rule, excellent dental results can be achieved with informed and cooperative patients. Thus, the following information is routinely supplied to anyone considering dental treatment in our office recognizing the benefits of a pleasing smile and healthy teeth, you should also be aware that dental treatment, like any treatment of the body, has some inherent risks and limitations. These risks and limitations usually do not contra-indicate treatment but should be considered in making the decision to submit to dental treatment.

Perfection is our goal. However, in dealing with human beings, and problems of growth and development, the ravages of dental disease, genetics and patient cooperation, achieving perfection is not always possible. Often a functionally and esthetically adequate result must be accepted. We will do everything within our capacity to insure the best possible care.

Throughout life teeth are constantly changing. Periodic examinations should be made so any disease can be treated promptly. Frequent professional visits are the best insurance against serious dental disease. Decay or gum disease can occur if patients do not brush and floss their teeth properly and thoroughly. Excellent oral hygiene and plaque removal is a must.

On rare occasions the nerve of a tooth may die and become infected. A tooth that has been damaged by deep decay, a minor blow or extensive dental treatment can die over a long period of time. An undetected non-vital tooth may flare up during any dental treatment, and may require endodontics (root canal) treatment to maintain it. It may even have to be removed. There is also a risk that during or following treatment soreness or tenderness may occur in the temporomandibular joints (lower jaw joints).

The total time for treatment can be delayed beyond our estimate. Treatment plans can change due to altered conditions which may surface during treatment. Decay which may appear small on x-ray, may be larger than anticipated resulting in much more extensive treatment.

Informed Consent

I understand that during treatment occasionally any of the above problems may occur. These can include but are not necessarily limited to: pain (discomfort), tooth mobility, tooth decay, devitalization (nerve loss), tooth and/or jaw changes, and injury resulting from the use of high speed dental equipment.

I understand that treatment alternatives will be explained (including the consequences of no treatment) as well as the preferred method of treatment for my mouth. I understand that for a successful result and to lessen the dangers of complication, the following conditions are essential on my part:

1.Excellent oral hygiene
2. Proper diet controls
3.Strict adherence to instructions
4.Cooperation in keeping appointments

I understand that there is no warranty or guarantee to my result and/or care, I also understand that I can, at any time, ask for and receive a full recital of all possible risk related to my treatment.

In addition, I understand that treatment may be discontinued for patients who fail two appointments without prior notification: who are constantly late for their appointments: who continue to excessively cancel their appointments: who fail to practice acceptable oral hygiene: or who are uncooperative with staff providing care.

Name(Required)

First Last

Date(Required)

Signature(Required)

We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment you may be preventing another patient from getting much needed treatment. Conversely, the situation may arise where another patient fails to cancel and we are unable to schedule you for a visit, due to a seemingly "full" appointment book.

1. Cancellation/No Show Policy Hygiene Appointment

If an appointment is not canceled at least 2 business days in advance you will be charged a seventy five dollar ($75) fee: this will not be covered by your insurance company.

2. Cancellation/ No Show Policy Doctor Appointment (NONREFUNDABLE DEPOSIT)

Due to the large block of time needed with the doctor, last minute cancellations can cause problems and added expenses for the office. For this reason we require a down payment of one hundred and fifty dollars ($150) when scheduling your appointment.

If a doctor's appointment is not canceled at least 2 business days in advance you will lose your one hundred and fifty dollar ($150) non refundable deposit.

3. Scheduled Appointments
We understand that delays can happen however we must try to keep other patients and doctors on time.

If a patient is 15 minutes past their scheduled time we will have to reschedule the appointment.

Name(Required)

First Last

Date(Required)

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