New Medical History form Patient Details

New Medical History form Contact Information

New Medical History form Insurance Information

Patient/Guradian Information 

(If different than patient)

Employment Informationa Patient/Guardian

Primary Insurance Details

  •  Yes
  •  No

Secondary Insurance Details

  •  Yes
  •  No

New Medical History form Medical History

  •  Allergies
  •  Codeine Allergy
  •  Penicillin Allergy
  •  Anemia
  •  Arthritis
  •  Artificial Joints
  •  Asthma or Respiratory problems
  •  Blood Disease
  •  Cancer or Tumers
  •  Diabetes
  •  Dizziness or fainting
  •  Epilepsy
  •  Excessive Bleeding
  •  Glaucoma
  •  HIV or AIDS
  •  Heart Disease
  •  Heart Murmur or MVP
  •  Hepatitis or Liver Disease
  •  High Blood Pressure
  •  Kidney Disease
  •  Mental Disorders
  •  Pacemaker
  •  Pregnancy
  •  Radiation or Chemotherapy
  •  Rheumatic Fever
  •  Sinus Problems
  •  Sjogren’s Syndrome
  •  Stomach Problems
  •  Stroke
  •  Tuberculosis
  •  Ulcers
  •  STD’s
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail.

New Medical History form Smile Assessment

Please consider each statement carefully and circle YES or NO to give us a better understanding of your needs.

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

New Medical History form Oral Screening Consent Form

Our practice continually looks for advances to ensure that we are providing the optimum level of oral health care to our patients. We are concerned about oral cancer and look for it in every patient

One American dies every hour from oral cancer. Late detection of oral cancer is the primary cause that both the incidence and mortality rates of oral cancer continue to increase. As with most cancers, age is the primary risk factor for oral cancer. Tobacco and alcohol use are other major predisposing risk factors but more than 25% of oral cancer victims have no such lifestyle risk factors. Oral cancer risk by patient profile is as follows:

Increased risk: patients ages 18-39 – sexually active patients (HPV 16/18)

High risk: Patients age 40 and older; tobacco users (any age, any type within 10 years)

Highest risk: Patients age 40 and older with lifestyle risk factors (tobacco and/or alcohol use); previous history of oral cancer

We have recently incorporated ViziLite Plus into our oral screening standard of care. We find that using ViziLite Plus along with a standard oral cancer examination improves the ability to identify suspicious areas at their earliest stages. ViziLite Plus is similar to proven early detection procedures for other cancers such as mammography, Pap smear, and PSA. ViziLite Plus is a simple and painless examination that gives the best chance to find any oral abnormalities at the earliest possible stage. Early detection of pre-cancerous tissue can minimize or eliminate the potentially disfiguring effects of oral cancer and possibly save your life. The ViziLite Plus exam will be offered to you annually.

This enhanced examination is recognized by the American Dental Association code revision committee as CDT 2007/08 procedure code D0431; however, this exam might not be covered by your insurance. The fee for this enhanced examination is $55.

  •  Yes. I authorize the clinician to perform the ViziLite Plus exam along with the standard oral cancer examination. I accept financial responsibility for this enhanced examination.
  •  No. I would prefer not to have the ViziLite Plus exam at this time.

New Medical History form General Consent

1. During the course of treatment, I may undergo procedures in all phases of dentistry. Some of the procedures may be performed by a dental profession other than the dentist including a dental assistant or dental hygienist that have been trained to perform certain tasks and is allowable by law.

2. I will provide a thorough and complete medical history, supply a full list of my medications with dosages, and consent to my dentist communicating with my other medical practitioners to inquire about any aspect of my health history.

3. No guarantees can be made about treatment outcomes, restoration longevity, or prognoses. I understand that any branch of medicine, including dentistry, can involve unanticipated results.

4. Payment is due the day of service and I am responsible for the full amount owed regardless of any insurance policy I may or may not have. The practice will help in filling any forms needed for insurance reimbursement and those payments will be given to the patient. There is no guarantee that an insurance company will cover work that may be performed.

5. My treatment plan may change at any time and I will do my best to approach my dental care with optimism and open communication with my dentist, hygienist, and dental office staff.

6. I am welcome to ask questions about any aspects of my dental care and will request information if I am confused or need more information. I am responsible for clarifying any aspects of my treatment that I am unsure about.

Most dental procedures require the use of dental anesthetic or numbing to complete the procedure. I understand that there are risks involved in using anesthetic which includes permanent or temporary loss of feeling and or muscle control from nerve damage, pain from injection site including muscle tightness or even muscle damage that may or may not go back to the normal, allergic reaction, and any other side effects as

New Medical History form Notice of Privacy Practices




We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.


We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.

Payment: We may use and disclose your health information to obtain payment for services we provide to you.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing, or credentialing activities. 

Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend, or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.

Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information. 

Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization. 

Required by Law: We may use or disclose your health information when we are required to do so by law.

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters.)


Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. You may also request access by sending us a letter to the address at the end of this Notice.)

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

Restrictions: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). 

Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. (You must make your request in writing.) Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances.

Electronic Notice: If you receive this Notice on our Web site or by electronic mail(e-mail), you are entitled to receive this Notice in written form.


If you want more information about our privacy practices or have questions or concerns, please contact us.
If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, You may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services. 

Acknowledgement: I, hereby acknowledge that I have read and fully understand the contents of this document, and I have been given the opportunity to ask any and all questions.

**You may refuse to sign this acknowledgment.

New Medical History form Office Policies

  •  As a courtesy, our office will submit claims to your insurance on your behalf. For any procedures not covered in full by your insurance, your portion will be estimated and due on the day of service. Although we try our best to estimate your portion accurately, it is your responsibility to know what your benefits are. The insurance policy is an agreement between you and the insurance company negotiated by your employer and is not a guarantee of payment. You are ultimately financially responsible for any services rendered.
  •  We do not offer in-office financing or payment plans, but do accept most major credit cards and are affiliated with CareCredit. They can be contacted on-line at to apply and see what payment plans are available.
  •  Please be sure to notify the office of any changes in your contact information; such as, address, phone numbers, e-mail, etc. Also, if your insurance policy changes or is no longer in effect, it is your responsibility to let us know prior to your next appointment.
  •  If, for any reason, you cannot keep your scheduled appointment, please call the office with at least 48 hours or there will be a charge. This allows us time to offer the appointment to another patient.
  •  As a courtesy, we will contact you to confirm a scheduled appointment. We have the capability to confirm appointments through e-mail and/or text messages. In addition to confirming appointments, e- mails can be used to notify you when you are due if you did not schedule in advance and to provide you with updates and office information. You have the option to opt out at any time.
  •  We do our best to keep to a schedule. When a patient is late it is impossible to stay on schedule. If you arrive past your scheduled appointment time, the appointment may be rescheduled so that other patients are not inconvenienced. If you are a new patient, please arrive 10 minutes prior to your appointment time.
  •  Records generated by our office can be copied and mailed upon receipt of a signed records release form. There will be a charge to cover the cost of equipment, supplies and postage.
  •  We do not get involved in separation or divorce disputes between the guarantor of the account and the person who registers the child at the time of visits. Therefore, if the guarantor is delinquent in paying the account, the balance will be transferred to the person who registers the child at the time of the visit.

I have read the office policies and I understand and agree to the terms stated above.

New Medical History form Authorization

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