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Mtvernonfamilydental.com


PATIENT INFORMATION ____ _ CONFIDENTIAL

Name_____________________________________ Birthdate___________________ Soc. Sec. #_________________________

Address
___________________________________
City_______________________ State______ Zip__________________

Sex (M/F)______ Marital Status____________
Home #______________________ Cell #___________________________

Employer_________________________________
Address_______________________________________________________

Work #
______________________ Length of Employment_______________ Position Title_________________________
Do you prefer to receive calls at: ____Home
____Work
____Either
Person to contact in case of an emergency:_____________________________ Phone #________________
How did you find out about our Office:________________________________________________________
SPOUSE OR PARENT/GUARDIAN INFORMATION______________________________________________

Name_____________________________________ Birthdate__________________ Relationship to Patient_______________

Address
___________________________________
City_______________________ State______ Zip__________________

Sex (M/F)______ Marital Status____________
Home #______________________ Cell #___________________________

Employer_________________________________
Address_______________________________________________________

Work #
______________________ Length of Employment_______________ Soc. Sec #_________________________

RESPONSIBLE PARTY_______________________________________________________________________

Name_____________________________________ Birthdate__________________ Relationship to Patient_______________

Address
___________________________________
City_______________________ State______ Zip__________________

Sex (M/F)______ Marital Status____________
Home #______________________ Cell #___________________________

Employer_________________________________
Address_______________________________________________________

Work #
______________________ Length of Employment_______________ Position Title_________________________
Is this person currently a patient at our office? _____Yes _____No Soc. Sec. #___________________________

INSURANCE INFORMATION_________________________________________________________________

Name of Primary Insured___________________________ Birthdate____________ Relationship to Patient_______________

Home #
______________________ Cell #_____________________ Employer_____________________________________

Dental Ins. Co. Name
___________________________ Phone #_________________ Subs. /Emp. ID #__________________

Dental Ins. Co. Address___________________________

City_________________ State________ Zip______________

Name of Secondary Insured________________________ Birthdate_____________ Relationship to Patient_______________
Home #_______________________ Cell#_________________________ Employer___________________________________
Dental Ins. Co. Name____________________________ Phone#___________________ Suds./Emp. ID#___________________
Dental Ins. Co. Address__________________________ City____________________ State_________ Zip________________


Please read each of the following policies completely before placing your initials on the corresponding line.
By placing your initials on the line you are agreeing that you have fully read and understand our office
policies.
AUTHORIZATION, RELEASE, and AGREEMENT TO PAY FOR SERVICES RENDERED_______
I authorize Dr. Volz to release any information including the diagnosis and the records of any treatment of
examination rendered to me during the period of such Dental care to third party payors and/or other health
practitioners. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to
be responsible for payment of all services rendered on my behalf or on behalf of my dependents. ___________

PAYMENT METHODS and FINANCE CHARGE_____________________________________________

There are two forms of payment that are accepted; those being personal check or cash. My portion of payment is
expected at the time of the service. Also if I do not pay the entire account balance within 30 days of the monthly
billing date, a finance charge of 2% per month or a minimum of $2.00 per month will be placed on my account. I
realize that failure to keep this account current may result in you being unable to provide additional dental services
except for dental emergencies or where there is prepayment for additional services. In the case of default on payment
of this account, I agree to pay collection costs and reasonable attorney fees incurred in attempting to collect on this
amount or any future outstanding account balances. ___________


CANCELLATIONS WITHOUT 24HR NOTICE OR FAILURE TO APPEAR_____________________

Canceling appointments without 24hr notice or failure to appear for a dental appointment will be handled in the
following way:
FIRST OCCURENCE: a verbal warning is given to patient or responsible party
SECOND OCCURENCE: a $30.00 fee is charged to your account and must be paid before any further
appointments are made
THIRD OCCURENCE: you must prepay for any scheduled treatment; however if that appointment is cancelled
without 24hr notice or failure to appear occurs, then the prepayment is forfeited __________
(INITIALS)
INFORMED CONSENT___________________________________________________________________

I give this practice permission to disclose or use my protected health information to carry out my treatment(s),
payment activities and health care operations. ___________


ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES________________

(You May Refuse to Initial This Acknowledgement)

I, _____________________________, have received a copy of this office’s Notice of Privacy Practices.
___________

(INITIALS)
IF SIGNING FOR A MINOR
Print Name of Minor___________________________________ Parent/Guardian of Minor Initials___________

I understand that by signing this form, that I have been informed of this Office’s policies.
Patient or Parent/Guardian’s Signature:___________________________________ Date:__________________

PATIENT MEDICAL AND DENTAL HISTORY__________________________________CONFIDENTAL
Physician Name____________________________________ Phone #___________________ Date of Last Exam________________

Please Circle Y for Yes or N for No
1. Are you under going medical treatment now 4. List any medications including non-prescription medications
Y N __________________________________________________________
__________________________________________________________
2. Have you ever been hospitalized for a _________________________________________________________ _
major operation or serious illness Y N

5. Please circle any of the following that you may be allergic to or
may have/had a reaction to
Local Anesthetics Penicillin Antibiotics Barbiturates
3. Do you use or have you ever used any
form of Osteoporosis preventing drugs Sulfa Drugs Aspirin Iodine
such as: Fosamax, Boniva, Actonel,
Skelid, Didronel, Zometa, and/or Aredia Please list Others__________________________________________
Y N _________________________________________________________
WOMEN ONLY:
1. Are you pregnant or think you may be pregnant Y N
2. Are you nursing Y N
3. Are you taking birth control pills/patch/shot/other Y N

Do you have or have you had any of the following? If yes, please mark with an X

_____Heart Attack/Problems
_Joint Replacement/Implant
Respiratory Problems
_____Emphysema/COPD
_ __Fainting/Seizures/Epilepsy
_____Tuberculosis
_____Stomach Ulcers
_____Hepatitis/Jaundice
_____Heart Murmur
AIDS/HIV+/STD
_____Nervous/Mental Problems
_____Seasonal Allergies
_____Cancer
_____High/Low Blood Pressure
_____Rheumatic Fever
Cold Sores
_____Diabetes
_____Excessive Bleeding
_____Radiation Therapy
_____Stroke
How long since your last dental visit?____________ How often did you visit a dentist before then?____________

Did you have x-rays? Y N How often do you brush your teeth___________ How often do you floss__________

Do you use alcohol and/or tobacco? Y N Do you use any other drug? Y N

Do you have any of the following habits: ____thumb/finger sucking Chewing on ____Cheek ____Tongue ____Lips
____Pencils/Pens ____Fingernails

Please mark an X by any of the following statements that may apply to you
_____Do your gums bleed while brushing or flossing _____Do you want to avoid dentures
_____Do you feel pain in your mouth or teeth _____Have you had pain in or around your ears
_____Have you had complications with extractions _____Do you clench or grind your teeth
_____Are your teeth sensitive to heat/cold/sweets/sour things _____Does food wedge between your teeth
_____Do you have sores/lumps in or near your mouth _____Do you experience popping, clicking, or
snapping when chewing
_____Do you have or ever had braces If so, when_____________

_____Have you ever had gum treatment or surgery If so, when______________
_____Have you had any head, neck, or jaw injuries If so, when______________
I certify that to the best of my knowledge the foregoing questions have been completely and accurately answered. I also
understand that providing incorrect information can be dangerous to my health.

Patient, Parent, Or Guardian Signature X Date

Source: http://mtvernonfamilydental.com/wp-content/uploads/2012/10/New-Patient-Form.pdf

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