New Patient Paperwork

New Patient Paperwork Download

-Or-

Complete the online form:

Patient Information

EMERGENCY INFORMATION

In case of emergency, please provide information for the nearest relative or designated contact person not at the patient’s address:

EMPLOYMENT INFORMATION

Insurance Information

Primary

Secondary Insurance (if applicable)

PREVIOUS DENTIST INFORMATION

DENTAL HISTORY

Are you currently having dental discomfort?

Any unhappy/unpleasant dental experiences?

Any injuries to mouth/teeth/head?

Any missing teeth other than wisdom teeth or orthodontic extractions?

Have missing teeth been replaced?

Orthodontic appliances now or in the past?

Gums bleed when brushing or flossing?

Concerned about gum disease? History of gum disease?

Any concerns about the appearance of your teeth?

Does it hurt to bite or chew?

Do you clench or grind your teeth? If so, do you wear a night guard or splint?

Do you want your mouth properly restored and pain free?

Does any type of dental treatment make you nervous? If yes, please explain below:

CHILD/MINOR PATIENTS: PLEASE ANSWER THE FOLLOWING QUESTIONS:

Any mouth habits? (thumb sucking, nail biting, mouth breathing, nursing/bottle habits, pacifier, etc.)

Any unusual speech habits?

Any lost teeth?

Does the patient receive assistance with brushing and flossing?

PRIMARY PHYSICIAN INFORMATION

MEDICAL HISTORY

GENERAL HEALTH:

Under a physician’s care now?

Any hospitalization in the past 5 years?

Any serious illnesses/surgeries?

Use tobacco in any form?

Is pre-medication required before dental visits due to heart condition or artificial joint?

Taking any prescription or daily OTC medications/drugs? If yes, list details in the Medication Section.

FEMALE PATIENTS: Currently Nursing Currently Pregnant

Do you know of any reason why routine dental procedures might pose a risk to you, our staff, or other patients?

Is there anything important about your medical condition we have not asked?

Do you have any of the following? Please check any that apply to you.

ARE YOU ALLERGIC TO OR HAVE YOU EVER HAD ANY REACTION TO THE FOLLOWING? (CHECK ALL THAT APPLY):

MEDICATION INFORMATION

ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING? (CHECK ALL THAT APPLY):

Enter the drug name, dosage and reason prescribed for any medications that you are currently taking.

Financial Guidelines

We are committed to providing you with the best care possible to achieve total oral health. In order to achieve these goals, we need your assistance and your understanding of our financial guidelines.

Insurance

We accept all major dental insurance payments, however we may not be an in network provider for your plan. If we are not an in network provider, review your plan details, as in many cases insurance reimbursement is very similar. Your insurance is a contract between You, Your Employer and the Insurance Company. Please remember that our relationship is with YOU! Your insurance is meant to reimburse the dentist for services retained by you, the patient.

  • We are in network for Delta Dental Premier, Aetna PPO and Cigna PPO.

  • No estimate is a guarantee of payment. Please understand, you are responsible for all charges not paid by your insurance. Also, many insurance companies are excluding certain dental procedures or downgrading procedures to a lesser reimbursement level; in which case, you would be responsible for the difference.
  • Minors must be accompanied by a parent or legal guardian. If the parents are separated or divorced, the person accompanying the minor will be responsible for copayment at the time of service.

Payments

  • Patient portion orpatient co-pay is due atthe time services are rendered - unless prior financial arrangements have been made.
  • Payment Information:
    • All major credit cards are accepted (Visa, MasterCard, Discover)
    • In some cases, it may be possible to pay treatment with 50% due on the day of initial treatment and the balance paid in one or two subsequent payments. The Treatment Coordinator will discuss these payment options with you.
    • Various financing options with CareCredit®
  • Balances left over 60 days will incur a $20 minimum monthly finance charge. We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in the management of your account.

Short Cancelled/ Missed Appointments/Miscellaneous Fee’s

  • In respect for all of our patients, we kindly request 2 business days in advance notice to change an appointment.
  • Short canceled or missed appointments – We reserve the right to charge for broken and/or missed appointments. Some appointments may require a deposit.


By signing below I acknowledge I have read and understand the guidelines above.

ACKNOWLEDGEMENT OF PRIVACY PRACTICES

Updated 2013

My signature confirms that I have been informed of my rights to privacy regarding my protected personal and health information, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I understand the terms in which my personal health and identification information may be used.

I have been informed of my dental provider’s Notice of Privacy Practices containing a more complete description of the uses and disclosures of my protected health information. I have been given the right to review and receive a copy of such Notice of Privacy Practices. I understand that my dental provider has the right to change the Notice of Privacy Practices and that I may contact this office 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 health care operations and I understand that you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

Please list any dependent children under the age of 18 also covered by this acknowledgement:

I give permission for the following communications to be used by Hoffman Dental (please check all that apply) :

I am granting permission for Hoffman Dental to disclose their identity to anyone who may answer my home, work or cell phone.

I am granting permission for Hoffman Dental to leave a message with any person who may answer my phone or on my voicemail of the following numbers (please check all that apply):

I would like to give permission for the following person(s) to have access to personal information including but not limited to appointments, treatment, and billing of myself and any dependent children listed above:

To the best of my knowledge, all of the preceding answers are correct. If I have any changes in my health status of if my medication changes, I shall inform the dentist and staff at the next appointment without fail.

I hereby authorize payment directly to Hoffman Dental of the dental benefits otherwise payable to me.

I hereby authorize Hoffman Dental to release any information concerning my health or dental care, advice, treatment or supplies provided. This information is to be used in administering dental claims and/or discussing treatment options with other dental professionals.

I hereby give my consent for Hoffman Dental to treat me and/or my family for our dental needs.

I understand and agree that (regardless of my insurance status) I am ultimately responsible for the balance on my account for any professional services rendered.

By signing below, I acknowledge that I have read and understand the statements mentioned above.