Adult New Patient Form | Grove Dental Associates

NEW PATIENT INFORMATION

ABOUT YOU

Patient Name:*

(First)

Middle Name

(Middle)

Last Name*

(Last)

Name Prefix

Mr.
Mrs.
Ms.
Dr.

I prefer to be called:

Sex :

Sex:

Male
Female

Birthday*

Birthday

Address*

City*

State*

Zip*

Home Phone:

Work:

Cell:

Social Security #:

Email:

Employer:

Occupation:

Emergency Contact:

Emergency Phone #:

SPOUSE INFORMATION

No spouse information

No spouse information

Spouse's Name

Spouse's Employer:

Primary Phone #:

Birthday:

DENTAL INSURANCE

We will gladly assist you in filing the claims for your primary insurance if provided with the necessary information and a copy of the insurance card.

Mark for no dental insurance

Mark for no dental insurance

Full name of the Policy Holder

Policy Holder SS#:

Policy Employer:

Policy Holder Birthday:

Relationship to Policy Holder:

Name of Insurance Company

Insurance Group #:

Member ID#:

Signature:

Date:

I understand that payment is expected on the day of each service. I realize I am also responsible for any remaining charges that my insurance company chooses not to pay.

REFERRED BY

Name of Referral:

Relationship of Referral:

Referral By:

DENTAL HEALTH INFORMATION

When was your last dental visit?

Name of previous dentist:

Do you have any current dental issues or concerns you would like to discuss or address

What (if anything) would you like to change about the appearance of your smile?

Do you have any fears about visiting the dentist (pain, cost, previous bad experience, lack of time, etc.)?

On a scale of 1 to 10 how would you rate your dental health? (1 being poor, 10 being excellent)

MEDICAL INFORMATION

Name of Primary Physician:

Date of last visit:

Any recent illness/doctor care or surgeries, please list:

List all medications you are currently taking:

Are you currently or have you ever taken any medication or bisphosphonates for osteoporosis?

Yes
No

All medical allergies

Other allergies:

Have you been told that you require antibiotic pre-medication prior to dental treatment?

Yes
No

Why?

Pregnant

Yes
No

Nursing

Yes
No

Taking birth control pills

Yes
No

Have you ever been treated for or experienced any of the following? (Please check all that apply.)

Do you have a history of any of the following? (Please check all that apply.)

Describe Your Heart Problem:

Other:

HIPAA FORM

I HAVE BEEN OFFERED AND/OR RECEIVED A COPY OF GROVE DENTAL ASSOCIATES’ NOTICE OF PRIVACY PRACTICES
I UNDERSTAND THAT MY PHI (PROTECTED HEALTH INFORMATION) CAN AND WILL BE USED FOR PURPOSES OF TREATMENT AND FOR PAYMENT FROM BOTH MYSELF AND/OR THIRD PARTY. I UNDERSTAND THAT I MAY REQUEST A COPY OF THE PRIVACY POLICIES AT ANY TIME.
I UNDERSTAND I MAY REFUSE TO SIGN THIS ACKNOWLEDGEMENT

I GIVE CONSENT FOR THE OFFICE OF GROVE DENTAL ASSOCIATES TO SHARE PERSONAL INFORMATION REGARDING APPOINTMENTS, TREATMENT, BALANCE, ETC, WITH THE FOLLOWING FAMILY MEMBERS/SPOUSE/FRIENDS/OTHER.
PLEASE LIST NAME / RELATIONSHIP AND SIGN BELOW OR PLEASE WRITE NO ONE IF YOU DO NOT WANT YOUR INFORMATION SHARED WITH ANYONE,

1. Name / Relationship

2. Name / Relationship

3. Name / Relationship

PRINT PATIENT NAME

PATIENT SIGNATURE OR PARENT/GUARDIAN SIGNATURE IF PATIENT IS A MINOR (UNDER 18)

PATIENT SIGNATURE

OR PARENT/GUARDIAN SIGNATURE IF PATIENT IS A MINOR (UNDER 18)

Date