New Patient Forms

Patient Forms

Patient Information

Address
Address
Address Line 1
Address Line 2
City
State/Province
Zip/Postal
For Text Confirmations

Primary Insurance Information

Insurance Address
Insurance Address
Street Address (line 1)
Street Address (line 2)
City
State/Province
Zip/Postal

Emergency Contact / Responsible Party Information

(will only be used for office communications)

Address
Address
Street Address (line 1)
Street Address (line 2)
City
State/Province
Zip/Postal

Patient Medical History

Have you ever been told you have one of the following?
Heart Disease
Bleeds Easily
Fainting/Seizures
Hay Fever/Allergies
Kidney Disease
Liver Disease
Hepatitis
Jaundice
Anemia
Swollen Ankles
AIDS/HIV
Emphysema
Rheumatic Fever
Stomach Ulcer
Thyroid Disease
Ashma
Heart Attack
Arthritis
Cancer
Diabetes I
Diabetes II
Stroke
Cancer in Remission
Heart Murmur
Shortness of Breath
Chest Pain - Angina
Epilepsy/Convulsions
High Blood Pressure
Low Blood Pressure
Leukemia
Glaucoma
Congenital Heart Defect
Joint Replacement/Implant
Recent Weight Loss
Psychiatric Treatment
Radiation Therapy
Mitral Valve Prolapse
Are you under any medical treatment now?
Have you ever had any other serious illness not listed above?
Are you currently taking any medications?
Have you ever had a bad reaction to local anesthetic or penicilin?
Do you use tobacco?
Do you use alcohol, cocaine, or other drugs?
(for women only) Are you pregnant or think you may be pregnant?
(for women only) Are you currently using birth control?

Patient Dental History

I certify that I have read and understand the above information. To the best of my knowledge, the above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health.

I understand that I am responsible for any account balance and payment in full is expected at the time of service, unless prior arrangements have been made. I authorize and request my insurance company to pay directly to Elite Smiles Dental any insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services and Elite Smiles Dental has no leverage on assuring that my claims will be be paid as estimated. As a courtesy to their patients, Elite Smiles Dental completes and files my insurance claims for me. I understand that I am responsible for any unpaid or denied claims. Thank you for understanding that as your dental care provider, our relationship is with you and not with your insurance company.

I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payers and/or health practitioners. I understand that Elite Smiles Dental complies with all HIPAA policies and regulations and that I may request a detailed outline of such policies.

Looking forward to giving you the smile that lights up the room!

Contact us, or schedule an appointment
Call Us Today: 661.222.7724