New Patient Form

Patient Information

Date

Name

Social Security #

Address

City

State

Zip

Phone

Cell Phone

Work Phone

Sex

Birthdate

Marital Status

Married

Widowed

Single

Minor

Separated

Divorced

Partnered For

Years

Occupation

Employer

How did you hear about us?

Do you prefer appointment confirmation by phone or email?

Dental Insurance - Primary

Who is responsible for this account?

Relationship to patient

Insurance Co.

Group #

Is patient covered by additional insurance?

Yes

Subscriber's Name

Birthdate

Social Security #

Relationship to patient

Insurance Co.

Group #

Dental Insurance - Secondary

Who is responsible for this account?

Relationship to patient

Insurance Co.

Group #

Is patient covered by additional insurance?

Yes

Subscriber's Name

Birthdate

Social Security #

Relationship to patient

Insurance Co.

Group #

Assignment and Release

I certify that I, and/or my dependent(s), have insurance coverage with
Name of Insurance Company(ies). I, the undersigned, certify that I (or my dependent) have insurance coverage and assign directly to Dr. Edward P. Laco all insurance 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 insurance. I hereby authorize the doctor to release all information necessary to secure the payments of benefits. I authorize the use of this signature on all insurance submissions.

Signature of Patient, Parent, Guardian, or Personal Representative

Please print name of Patient, Parent, Guardian, or Personal Representative

Relationship to patient

Date

Medical History

Patient Name:

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body, Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Are you under a physician's care now?

Yes

N/A

Have you ever been hospitalized or had a major operation?

Yes

N/A

Have you ever had a serious head or neck injury?

Yes

N/A

Are you taking any medications, pills, or drugs?

Yes

N/A

Pharmacy

Physician's Name

Emergency Contact/Number

Do you use controlled substances?

Yes

N/A

Women: Are you

Pregnant/Trying to get pregnant?

Nursing?

Taking oral contraceptives?

Have you had any serious illness not listed above?

Yes

N/A

List Of Medications

*Condition may require medication

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

Signature of patient, parent, or guardian

Date

Dental History

Name

Your current dental health is

Good

Fair

Poor

When was your last dental cleaning?

When was your last dental visit?

Do you require antibiotics before dental treatment?

Yes

Are you currently in pain?

Yes

Have you ever had periodontal treatment?

Yes

Do you now or have you had any pain/discomfort in your jaw? (TMJ)

Yes

Have you ever had any injuries to your head or neck?

Yes

Are your teeth sensitive to cold or anything else?

Yes

Have you lost any teeth?

Yes

Are you wearing any dentures or partials?

Yes

Have you ever had any serious/difficult problems with any previous dental work?

Yes

Are you happy with the way your teeth look?

Yes

Are you happy with the way your teeth feel?

Yes

Is there anything you would like to change about your smile?

Yes

Dr. Laco offers a wide variety of services to enhance and keep your smile beautiful. Please check any services below that you would like our friendly staff to discuss with you during your visit:

Acknowledgement of receipt of statement of privacy practices

I acknowledge that I have received a copy of the Statement of Privacy Practices for the offices of Edward P. Laco, DDS, PC. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility.

Edward P. Laco, DDS, PC reserves the right to change the privacy practices currently described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed or otherwise transmitted to me.

Additional Disclosure Authorization

In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my Protected Healthcare Information to the person(s) identified below. (I understand that the default answer is "NO". Without indicating "YES" in answer to each individual question, protected health information (PHI) cannot be shared with anyone unless otherwise allowed by HIPAA rules.)

Spouse Only

Yes

Any member of my immediate family: (i.e. Spouse, Children, Siblings, etc.)

Yes

Any member of my extended family: (i.e. Parents, Grandchildren)

Yes

Other

Yes

Name of Patient

Patient signature

Patient's personal representative

Personal Rep's signature

Representative's Phone Number

Date

Office use only below this line

Acknowledgement Not Obtained

Provided Prior to Treatment?

Yes

Date Statement Provided

Reason for not obtaining patient signature

Needed more time to review statement

Wanted to consult another person before signing

Physically unable to sign

No reason offered

Other

Patient Validation

Print Form