(386) 677-6424


115 East Granada Blvd, Suite 11
Ormond Beach, FL 32174


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Dr. Martha V. Smyth
Dentist Ormond Beach - 5 Stars

She is knowledgeable and is concerned about her patients.

The staff is congenial and helpful. My friend recommended me to her




Patient Form



Welcome to Dr. Martha's Office.

We would like to welcome you to our office. Our goal is to make every visit pleasant and educational. Our practice is based on preventative care. We strive to teach good oral care that will enable you a beautiful smile that will last a lifetime.

Please take a moment to print our new patient/s forms or click below to submit your forms online
Online Adult New Patient Form
Online Child New Patient Form

Submit Online Adult New Patient

Patient Information


Full Name: Last
First
MI
Address:
APT/Unit #:
City:
State:
Zip code:
Primary Phone:
Alternate Phone:
Work Phone #:
E-mail Address:
Date of Birth (MM/DD/YYYY):
Employer:
Whom may thank for referring you to our office?

Dental History


1. Do you want to keep your teeth?
2. Do you like your smile?
3. Would you change something?
Color
Shape
Straighten
4. Have you ever been told you have/or been treated for gum disease?
5. When was your last dental cleaning and check up?
6. What if anything has kept you from the dentist in the past year?
Fear
Cost
PLEASE CHECK ANY AND ALL OF THE FOLLOWING THAT APPLY TO YOU:
Swollen or Bleeding Gums
Painful Gums of Teeth
Loose Teeth
Bad Breath/Mouth Odors
Sensitivity to Hot/Cold/Sweet
Increasing spaces between teeth
Bad Tastes
Clench or Grind
Other

Medical History


Do you have any allergies that you are aware of?
Latex
Codeine
Acrylic
Penicillin
Metals
Aspirin
Sulfa Drugs
Local Anesthetics
Other
Have you had a joint replaced?
Yes
No
Heart stents placed?
Yes
No
Have you been told that you need to take antibiotics before dental work?
Yes
No
If YES what do you take?
Have you ever been treated for thin bones (Osteoporosis, Osteopenia)? If yes, which of the following medication have you taken?
Fosamax
Skeud
Didronel
Boniva
Ostac
Other
Are you currently under the care of a physician for something other than routine care?
Yes
No
If yes,
Do you smoke?
Yes
No
Use other tobacco i.e. chew?
Yes
No
Are you on an aspirin regime?
Yes
No
If yes,
Please check the following:
Yes
No
Please check the following:
Yes
No
High Blood Pressure
Yes
No
Emphysema
Yes
No
Low Blood Pressure
Yes
No
COPD
Yes
No
Heart Problems
Yes
No
Asthma
Yes
No
Heart Bypass Surgery
Yes
No
Tuberculosis
Yes
No
Angina
Yes
No
Epilepsy/Seizures
Yes
No
Heart Attack
Yes
No
Headaches
Yes
No
Pacemaker
Yes
No
Blood Disorders
Yes
No
Stroke
Yes
No
H.I.V. positive
Yes
No
Kidney Disease
Yes
No
Aids or related
Yes
No
Dialysis
Yes
No
Cancer
Yes
No
Chemical Dependency Treatment
Yes
No
Radiation/Chemo
Yes
No
Hepatitus/Liver Disease
Yes
No
Diabetes
Yes
No
Thyroid Disorders
Yes
No
Arthritis
Yes
No
Bleeding Problems
Yes
No
Women Only: Pregnant
Yes
No
Are you trying to become pregnant?
Yes
No
Breast Feeding
Yes
No
Taking Oral Contraceptives
Yes
No

Medications


If you have a list with you that we can photocopy, please give it to the receptionist. Otherwise please list all prescribed, over the counter, and supplements you are taking including drug name and dosage.
By checking this box and signing below you are electronically acknowledging the above statement.
Signature
Date

Our Office Policies


There are certain key things we would like you to know about us and how we do things to insure you receive the best care we can offer. We have these policies to prevent any misunderstandings. Communication is very important to us. We encourage you to ask any questions you may have about our office or your treatment.

**Insurance: Dr. Smyth is NOT in network with any insurance companies other than Delta Dental Premier. Please realize our services are provided to you, our patient, not to insurance companies. It is your responsibility to review your individual policy as they are all different. Certain policies stipulate frequency for cleanings and exams as well as waiting periods. We cannot and do not profess to know the specifics of every policy. We are happy to file your insurance for you, with the understanding that you are responsible for anything insurance does not cover.

Office Visits: To provide the best quality dental care, new patient x-rays are required. Additionally, x-rays are required for emergency visits to determine the problem and decide on treatment Periodontal (gum) disease, decay (cavities) and other pathology may be missed without x-rays to supplement the clinical examination.

Fees: Payment in full is due at the time the service is rendered. We accept cash, check, Visa, Mastercard, and Discover. We are always glad to discuss fees in advance, with the understanding that any fee quoted is an estimate and may be slightly higher or lower, depending on the extent of the procedure involved.

No-Shows: For any established patient who does not show and does not call to cancel his/her appointment, there is a minimum broken appointment fee of $50. Continued no-shows will result in discharge from the practice.

Special Requests for payment arrangements must be made in advance and in writing prior to scheduling an appointment. Please speak to the receptionist.
By checking this box and signing below you are electronically acknowledging the above statement.
Signature
Date

Acknowledgement of Receipt of Notice of Privacy Practices


I, , have received a copy of this office's Notice of Privacy Practices.
Signature
Date

Submit Online Child New Patient

Patient Information


Full Name: Last
First
MI
Address:
APT/Unit #:
City:
State:
Zip code:
Primary Phone:
Alternate Phone:
E-mail Address:
Interests, Sports or Hobbies:
Date of Birth (MM/DD/YYYY):
Male
Female
Referred by:
Sibling's Names and age (if any):

About Parents


Mother's Information

Full Name: Last
First
MI
Address:
APT/Unit #:
City:
State:
Zip code:
Primary Phone:
Alternate Phone:
E-mail Address:
Employer:
Work Phone #:

Father's Information

Full Name: Last
First
MI
Address:
APT/Unit #:
City:
State:
Zip code:
Primary Phone:
Alternate Phone:
E-mail Address:
Employer:
Work Phone #:

Dental Insurance Information


Insurance Name:
Phone#:
Group#:
Insured by:
Mother
Father
Other Relationship to Patient
Insured's Name:
Employer:
Birth Date of Insured:
Social Security # Insured:

Medical/Dental History


Please check all that applies to the patient:
Anemia
Asthma, Lung Problems
Bleeding Problems
Blood Pressure Problems
Cerebral Palsy
Cleft Lip/Palate
Delayed Development
Local Anesthetics
Diabetes
Ear Infections
Emotional Disturbances
Fainting Spells
Hearing Loss, Impairment
Pregnant
Herpes
Kidney Disease
Rheumatic Fever
Liver Disease, Hepatitis
Malignancy, Cancer
Mental Retardation
Heart Conditions, Murmur
Immunologic Disorder/HIV
Seizures, Epilepsy
Psychiatric Problems
Sickle Cell Anemia
Is your child ALLERGIC or has had an ADVERSE REACTION to any medication?
Yes
No
If yes,
Please list any medications child is currently taking:
Any Problems Not Listed above:
Child's Physician Name:
Last Exam Date:
Immunizations up to date:
Yes
No
Is this your child's 1st visit to the dentist:
Yes
No
If NO last visit Date?
Is your home supplied by:
well or
city Water?
Does your Child receive Fluoride-tablets, drops, vitamins or rinse?
Yes
No
Has your Child ever had Orthodontic Treatment?
Yes
No
Does your child brush his/her teeth daily
Yes
No
Do you assist?
Yes
No
Does your child suck his/her thumb or finger or similar habits?
Yes
No
What age was bottle or breast feeding stopped?
Has your child complained about pain, swelling or other problems?
Yes
No
If YES please note complaint:
Are you and/or your child happy with his/her:
Facial Appearance?
Yes
No
Appearance of teeth?
Yes
No
Would you predict your child's behavior to be:
Cooperative
Fearful
Defiant
Don't Know
What are your concerns about your child's oral health?
I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence, and that it is my responsibility to inform this office of any changes in my child's medical status. Your child is a minor; therefore it is necessary that signed permission be obtained from a parent or guardian before necessary dental services can be started. All necessary treatment will be explained prior to commencement.
The parent or guardian who accompanies the child is responsible for payment at the time services are rendered unless prior arrangements have been approved.
By checking this box and signing below you are electronically acknowledging the above statement.
Parent/Guardian
Date

Financial Agreement


I acknowledge that payment is due at the time of treatment, unless other arrangements are made. I agree that parents/guardians are responsible for all fees and services rendered for treatment of a minor child. I accept full financial responsibility for all charges not covered by insurance.

In the event my account balance remains unpaid in excess of 90 days, I understand that my account will be turned over to a collection agency. I accept full responsibility for all administrative costs and legal fees associated with the collection process.

Assignment and Release


I, the undersigned, have insurance with and assign directly to the dentist all benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by my insurance within 60 days from the date of service. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions whether manual or electronic.

I understand that there is a broken appointment policy and that I will be charged $30.00, unless I notify the office within 1 business day of my cancellation.

For your convenience our office takes personal checks. However, I understand a $50.00 fee will be applied to my account for any bounced check (NSF) and from that point forward, personal checks will no longer be an acceptable form of payment.
By checking this box and signing below you are electronically acknowledging the above statement.
Signature
Date

Acknowledgement of Receipt of Notice of Privacy Practices


I, , have received a copy of this office's Notice of Privacy Practices.
By checking this box and signing below you are electronically acknowledging the above statement.
Signature
Date