Patient Form in Ormond Beach

Online Adult New Patient Form

Online Child New Patient Form

Submit Online Adult New Patient

Patient Information

Full Name: Last

First

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

Heart stents placed?

Yes

Have you been told that you need to take antibiotics before dental work?

Yes

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

If yes,

Do you smoke?

Yes

Use other tobacco i.e. chew?

Yes

Are you on an aspirin regime?

Yes

If yes,

Please check the following:

Yes

Please check the following:

Yes

High Blood Pressure

Yes

Emphysema

Yes

Low Blood Pressure

Yes

COPD

Yes

Heart Problems

Yes

Asthma

Yes

Heart Bypass Surgery

Yes

Tuberculosis

Yes

Angina

Yes

Epilepsy/Seizures

Yes

Heart Attack

Yes

Headaches

Yes

Pacemaker

Yes

Blood Disorders

Yes

Stroke

Yes

H.I.V. positive

Yes

Kidney Disease

Yes

Aids or related

Yes

Dialysis

Yes

Cancer

Yes

Chemical Dependency Treatment

Yes

Radiation/Chemo

Yes

Hepatitus/Liver Disease

Yes

Diabetes

Yes

Thyroid Disorders

Yes

Arthritis

Yes

Bleeding Problems

Yes

Women Only: Pregnant

Yes

Are you trying to become pregnant?

Yes

Breast Feeding

Yes

Taking Oral Contraceptives

Yes

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

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

Address:

APT/Unit #:

City:

State:

Zip code:

Primary Phone:

Alternate Phone:

E-mail Address:

Employer:

Work Phone #:

Father's Information

Full Name: Last

First

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

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

Is this your child's 1st visit to the dentist:

Yes

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

Has your Child ever had Orthodontic Treatment?

Yes

Does your child brush his/her teeth daily

Yes

Do you assist?

Yes

Does your child suck his/her thumb or finger or similar habits?

Yes

What age was bottle or breast feeding stopped?

Has your child complained about pain, swelling or other problems?

Yes

If YES please note complaint:

Are you and/or your child happy with his/her:

Facial Appearance?

Yes

Appearance of teeth?

Yes

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

Patient Form

Welcome to Dr. Martha's Office.

Submit Online Adult New Patient

Patient Information

Dental History

Medical History

Medications

Our Office Policies

Acknowledgement of Receipt of Notice of Privacy Practices

Submit Online Child New Patient

Patient Information

About Parents

Dental Insurance Information

Medical/Dental History

Financial Agreement

Assignment and Release

Acknowledgement of Receipt of Notice of Privacy Practices

Links

Services