Complete the online form:
In case of emergency, please provide information for the nearest relative or designated contact person not at the patient’s address:
Are you currently having dental discomfort? No Yes If yes, explain:
Any unhappy/unpleasant dental experiences? No Yes If yes, explain:
Any injuries to mouth/teeth/head? No Yes If yes, explain:
Any missing teeth other than wisdom teeth or orthodontic extractions? No Yes
Have missing teeth been replaced? No Yes
Orthodontic appliances now or in the past? No Yes
Gums bleed when brushing or flossing? No Yes
Concerned about gum disease? History of gum disease? No Yes
Any concerns about the appearance of your teeth? No Yes
Does it hurt to bite or chew?No Yes
Do you clench or grind your teeth? If so, do you wear a night guard or splint? No Yes
Do you want your mouth properly restored and pain free? No Yes
Does any type of dental treatment make you nervous? If yes, please explain below: No Yes If yes, explain:
The most important concerns regarding my dental treatment are:
What factors are most important for your satisfaction with our office?
Any additional concerns/comments?
Any mouth habits? (thumb sucking, nail biting, mouth breathing, nursing/bottle habits, pacifier, etc.) No Yes If yes, explain:
Any unusual speech habits? No Yes If yes, explain:
Any lost teeth? No Yes If yes, list:
Does the patient receive assistance with brushing and flossing? No Yes If yes, how often?
GENERAL HEALTH: EXCELLENT GOOD FAIR POOR
Under a physician’s care now? No Yes
Any hospitalization in the past 5 years?No Yes If yes, explain:
Any serious illnesses/surgeries?No Yes If yes, explain:
Use tobacco in any form? No Yes If Yes, Type
Is pre-medication required before dental visits due to heart condition or artificial joint? No Yes
Taking any prescription or daily OTC medications/drugs? If yes, list details in the Medication Section.No Yes
FEMALE PATIENTS: Currently Nursing No Yes Currently Pregnant No Yes Due Date
Do you know of any reason why routine dental procedures might pose a risk to you, our staff, or other patients? No Yes If yes, explain:
Is there anything important about your medical condition we have not asked? No Yes If yes, explain:
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):
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.
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.
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.
Short Cancelled/ Missed Appointments/Miscellaneous Fee’s
By signing below I acknowledge I have read and understand the guidelines above.
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) : Cell Phone Text Message reminders permitted Home phone Work E-Mail
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): Cell Phone Home phone Work Phone None- please just ask for a call back
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.