New Patient Full - Adult Step 1 of 4 25% About YouToday's Date* Name* First Middle Last Email I prefer to be called Gender* Male Female Rather not say Birthdate* Home Address* City/State* Zip* Marital Status Single Married Divorced Widowed Separated Home Phone Cell* Work Phone + Ext Employer Employer Address Employment Length Occupation When and where are the best times to reach you? Whom may we thank for referring you? Other family members seen by us Previous/Present Dentist Last Visit Date Account ResponsibilityWho is responsible for the account?* Same as patient Listed below Account Responsibility DetailsNot the patient, please fill out all fields below.Person Responsible for the Account* Primary Phone* Work Phone + Ext Billing Address* City/State* Relation* SS#* Employer ID#* Spouse InformationHis/Her Name Employer Work Phone SS# Birthdate ID# InsuranceDental Coverage?* Yes No Insurance DetailsInsurance Co. Name* Insurance Co. Address* Insurance Co. Phone #* Group# (Plan, Local or Policy#)* Insured's Name* Relation* Insured's Birthdate* Insured's ID #* Insured's Employer Employer's Address Neighbor or Relative not living with youHis/Her Name Relation Home # Work # Home Address City/State/Zip Personal PhysicianDo you have a personal physician?* Yes No Personal Physician DetailsPhysician's Name* Phone* Date of last visit* Physician CareAre you under the care of a physician?* Yes No Please explain* Your current physical health is:* Good Fair Poor Do you smoke or use tobacco in any form?* Yes No Have you had any metal rods, pins, implants?* Yes No Are you taking any prescription/over the counter or herbal supplement drugs?* Yes No Please list each one* Have your ever taken Fosomax, or any other bisphosphonate?* Yes No Have you ever taken Phen-Fen?* Yes No Have you ever been advised to take an antibiotic prior to dental treatment?* Yes No If yes, what provider/MD prescribed the medication for you and what was the name of the medication prescribed to you?* Have you ever had any of the following disease or medical problems?Abnormal Bleeding* Yes No Alcohol/Drug Abuse* Yes No Anemia* Yes No Artificial Bones/Joints/Valves* Yes No Asthma* Yes No Blood Transfusion* Yes No Cancer/Chemotherapy* Yes No Colitis* Yes No Congenital Heart Defect* Yes No Diabetes* Yes - Type 1 Yes - Type 2 No Difficulty Breathing* Yes No Emphysema* Yes No Fainting Spells* Yes No Frequent Headaches* Yes No Glaucoma* Yes No Hay Fever* Yes No Heart Attack* Yes No Heart Murmur* Yes No Heart Surgery* Yes No Hepatitis* Yes - A Yes - B Yes - C Yes - D Yes - E No Herpes/Fever Blisters* Yes No High Blood Pressure* Yes No HIV+/AIDS* Yes No Hospitalized for Any Reason* Yes No Kidney Problems* Yes No Liver Disease* Yes No Low Blood Pressure* Yes No Lupus* Yes No Mitral Valve Prolapse* Yes No Osteoporosis/Paget's Disease* Yes No Pacemaker* Yes No Psychiatric Problems* Yes No Radiation Treatment* Yes No Rheumatic/Scarlet Fever* Yes No Seizures* Yes No Shingles* Yes No Sickle Cell Disease/Traits* Yes No Sinus Problems* Yes No Stroke* Yes No Thyroid Problems* Yes No Tuberculosis (TB)* Yes No Ulcers* Yes No Venereal Disease* Yes No Have you ever had a serious medical condition or hospitalization?* Yes No Please list any past serious medical conditions and hospitalizations:* Are you allergic to any of the following?Aspirin* Yes No Codeine* Yes No Dental Anesthetics* Yes No Erythromycin* Yes No Latex* Yes No Penicillin* Yes No Tetracycline* Yes No Are there other drugs or materials you are allergic to?* Yes No Please list any other drugs/materials that you are allergic to:* Birth Control/PregnancyAre you pregnant?* Yes No Are you using a prescribed method of birth control?* Yes No Pregnancy DetailsWeek #* Are you nursing?* Yes No Dental HistoryWhy have you come to the dentist today?* Are you currently in pain?* Do you require antibiotics before dental treatment?* Yes No Reason if yes* Have you ever had a difficult problem associated with any previous dental work?* Yes No Have you ever had gum treatment?* Yes No Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ)?* Yes No Your current dental health is:* Good Fair Poor Do you like your smile? Yes No Do your gums ever bleed?* Yes No How many times a week do you floss?* How many times a day do you brush?* What type of bristles?* Soft Medium Hard How long do you use a toothbrush before you replace it?* Are your teeth sensitive to heat, cold or anything else?* Have you lost any teeth?* Yes No If yes, why?* I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. Payment is due in full at the time of treatment unless prior arrangements have been approved. If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs fo dental treatment. I hereby authorize release of any information, including the diagnosis and records of treatment or examination rendered, to my insurance company. Signature of Patient or Guardian* Please Note: Typing your name in the signature field will be treated as equal to a physical signature in our office. Our office is HIPPA Compliant and committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.Signature Date* My Personal InformationName* First Middle Last Date of Birth* Phone Number* Emergency ContactName* Relationship* Phone Number* Primary Care PhysicianDo you have a primary care physician?* Yes No Primary Care Physician DetailsName* Phone Number* Preferred Pharmacy/DrugstoreName Phone Number Other PhysiciansPhysician InfoClick the + icon at right to add rows.NameSpecialtyPhone Number My AllergiesDo you have any allergies?* Yes No Please list all allergies:*My Medical ConditionsDo you have any medical conditions?* Yes No Please list all medical conditions:*MedicationsBe sure to include ALL prescription drugs, over the counter drugs, vitamins and herbal supplements.Click the + icon at right to add rows.Click the + icon at right to add rows.What I'm takingForm (pill, injection, etc)DosageHome much and whenUse (regularly or occasionally)Start/Stop Dates (01/01/19-02/01/19)(01/01/19-ongoing)Notes, directions, reasons for use Signature of Patient or Guardian* Please Note: Typing your name in the signature field will be treated as equal to a physical signature in our office. Our office is HIPPA Compliant and committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.Signature Date* Name* First Middle Last Date of Birth* General Release of Information I authorize Pospisil Family Dentistry to release and/or discuss any of my written records (including x-rays), confidential information, treatment, financial aspects, and all other material to the person(s) indicated below: [check the appropriate box or boxes] Can we release your information to others?* Yes No Person(s) authorized to receive your information:Name* Email Phone Authorize:* Release Records Discuss Leave a message Voice Text Name Phone Email Authorize: Release Records Discuss Leave a message Voice Text Name Phone Email Authorize Release Records Discuss Leave a message Voice Text How to ContactPhone* Leave a message Voice Text Secondary Phone Leave a message Voice Text Signature of Patient or Guardian* Please Note: Typing your name in the signature field will be treated as equal to a physical signature in our office.Signature Date* Our office is committed to providing you with the best possible care. In order to achieve this goal, we need your assistance and understanding regarding our office policies. When you reserve an appointment with our office, we have set aside time and resources just for you. If you're unable to keep your reserved appointment time, our office requires a 24 hour notice in order to avoid a Broken Fee of $50.00. Our office offers a courtesy of reminder call or text, however it is your responsibility to know when you schedule your dental a appointments are and to arrive on time. If you are more than 10 minutes late, we reserve the right to reschedule your appointment. Payments for Treatment:Payment is due at the time of treatment is provided. We accept cash, checks all major credit cards and CareCredit (you must apply and be approved). Insured Patients: As a courtesy, we will process your insurance claims for you. Please understand the following: Your insurance contract is between you, your employer and the insurance company. We are not a party to that contract. Not all treatment is covered benefits in each contact. Some insurance companies arbitrarily select certain treatment that they will not cover. A few insurance carriers' reimbursement policies are baed on an arbitrary "schedule" of fees for specified treatment (how often a series will be covered/how many are covered in the year(s)/lifetime/dollar amount allowed per tooth). These restrictions bear no relationship to the standard of cost for care in this area, and are absolute in their structure. Some insurance companies do not pay for resin fillings (tooth colored fillings) however, an alternate benefit is allowed, therefore you will be responsible for the difference in fees. The State of Arizona has approved legislation prohibiting dental insures from requiring a contracted dentists to accept a discount to their original submitted charges for any service that is not covered (non-covered) under the member's policy. The contracted dentists is required to accept approved amount for covered services only. If your insurance company does not pay within 45 days, you will be responsible for the full balance. We will provide you with the necessary paper work for reimbursement All charges are your responsibility regardless of any insurance benefits. All Patients: Please be aware of the following: Financial Responsibility: I agree to pay all finance charges, collection costs, attorney fees, and any other cost that may be incurred to enforce collection of any amount outstanding not paid by me. The charge for each returned check is $50.00. Signature of Patient or Guardian* Please Note: Typing your name in the signature field will be treated as equal to a physical signature in our office.Signature Date* NameThis field is for validation purposes and should be left unchanged.