MOUNTAINSIDE DENTAL GROUP

NEW PATIENT FORM

DATE:

Name:
* Single * Married

* Child

* Other

* Female

* Male

* Female

Date of Birth
Home #

Home Address:

City

* Male

Zip

State

Cell #

Email:
PERSON RESPONSIBLE FOR ACCOUNT
Name:

Date of Birth:

Relationship to above:
SSN#:

Cell#

Home #

Home Address:

City

State

Zip

Email:
DENTAL INSURANCE INFORMATION

Do you have Dental Insurance *yes / *no

Primary Insurance:
Employer:

Work #

Insurance Co. Name:

Phone #

ID #

Group #

Insured's Name:

Date of Birth:

Insured SSN#

Relationship to Patient:

Secondary Insurance:
Employer:

Work #

Insurance Co. Name:

Phone #

ID #

Group #

Insured's Name:

Date of Birth:

Insured SSN#

Relationship to Patient:

APPOINTMENT POLICY
We value your time, so you can expect us to see you at your appointed time. In return, when
you make an appointment with us please be on time. Please make every effort not to change
your scheduled appointment. If you must change an appointment, please provide us with
least 24 hours notice so that we may use our time to accommodate other patients. A $40.00
fee will be assessed if a 24 hour notice has not been given. By signing below I agree to

Signature:

Date:

MEDICAL HISTORY
NEW PATIENT FORM
Allergies:
*Yes *No
Aspirin
*Yes *No
Codeine
*Yes *No
Latex

DATE:
*Yes *No Erythromycin
*Yes *No Dental Anesthetics
*Yes *No Metals

*Yes *No
*Yes *No
Other:

Penicillian
Tetracyclin

Name of Physician:
Phone #
Do you have or have ever had any of the following?
Please check all that apply.

Allergies / Hay Fever

Frequent cough
Osteoporosis

Anemia
Glaucoma
Radiation Treatment

Angina
Heart Disorder
Respiratory Problems

Arthritis
Heart Infection*
Rheumatic Fever

Artificial Joints*
Heart Murmur*
Rheumatism

Artificial Heart Valves*

Heart Surgery
Sickle Cell Disease

Asthma
Hepatitis
Sinus Problems

Blood Transfusion
High Blood Pressure
Stroke

Cancer / Chemotherapy
HIV* / AIDS
Surgical Shunt*

Chemical Dependency
Kidney Problems
Thyroid Problems

Diabetes
Liver Problems
Tuberculosis

Epilepsy or Seizures
Mental Disorders
Ulcers

Fainting or Dizziness
Mitral Valve Prolaps
Venerea lDisease

Fever Blister / Cold sores

Pace Maker
Yellow Jaundice
* Condition may require antibiotic premedication for certain dental procedures.
Do you have any health problems that were not listed / or need further clarification?
If yes, explain:
Are you under the care of a physician?
If yes, explain:
Have you been admitted to a hospital during the last two years?
If yes, explain:
Have you used tobacco / recreational drugs ?
If yes, explain:
Please List All Medications / Herbal Supplements:

Women: (Please check)

Pregnant

Nursing

Trying to get Pregnang

To the best of my knowledge, all the preceding answers are correct. If I have any changes
in my health status or if my medications change, I will inform the dentist and the staff at my
next appoitnment without fail
Signature:
Parent or guardian signature:

Date:

Dental Health Information

NEW PATIENT FORM
Date of Last Dental Visit:

DATE:
Date of Laxt X-rays:

Mark "Yes" or "No" to indicate if you presently have or previouly had any of the following:

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Bad Breath
Bleeding gums
Chew on one side of mouth
Food collection between teeth
Gums swollen or tender
Pain around ear
Sensitivity to cold
Clicking or popping of the jaw
Difficulty in opening or closing mouth?
Bite your lips or cheeks regularly
Blister on lips or mouth
Dry Mouth
Grinding Teeth
Jaw pain or tiredness
Periodontal (gum) treatment
Pain? (joint, ear, side of face)

If yes to any of the above please explain:

How often do you floss?

How often do you brush?
Do you require antibiotics prior to dental treatment?
Are you currently in pain?
Have you ever had a serious / difficult problem associated with any preivous dental work?
Is there anything else about having dental treatment that you would like us to know?

NOTICE OF PRIVACY FOR PROTECTED HUMAN INFORMATION (HIPPA)

I hearby acknowledge that I have been offered a copy of this practice's Notice of Privacy
Practices. I understand that this practice follows all HIPPA regulations.
I understand that I may ask any questions I might have regarding this notice.
Signature:

Date:

Financial Policy
NEW PATIENT FORM

DATE:

Our office strives to provide the highest quality of care to all our patients. We proudly offer
the following financial policy so that our patients can have the opportunity to decide which

INSURANCE:
We will gladly bill your insurance for you and will work with you to help you maximize your
dental benefit. We do this as a courtesy for our patients. Because the insurance policy is
an agreement between you and your insurance company, the ultimate responsibility for all
charges lies with you. If after 60 days the insurance company has not paid on the claim,
you will be responsible for the total balance.
Most dental insurances do not cover 100% of the cost of treatment. Because of this you will
be asked to pay your deductable and any estimated charges on the day service is rendered.
We will estimate as closely as possible, due can make no guarantee of any estimated
coverage.

PAYMENT OPTIONS:
1.

Cash or Check

2.

Credit Cards / We accept VISA, MasterCard, Discover and American Express

3.

Care Credit: Care Credit is an outside finance company that you can apply
for a line of credit. They offer anywhere from six to nine months 0%
financing depending on the amount financed.

Only two (2) statements will be sent. If the balance on your account is not paid in full and you
have not contacted our office with payment that is suitable to both us and yourself, your
account will be turned over to an outside collection agency. In the event your account is
turned over, you will be responsible for payment of any collection costs and/or attorney fees,
in addition to the balance owed.

I (we) have read the above financial policy and understand all payment options.

Signature of Patient:
Signature of parent or guardian:

Date: