NEW PATIENT FORM

Name:
Birth Date:
Social Security #:
Home Address:
Home Phone:
City:
State:
Zip:
Cell Phone:
Email Address:
Preferred contact method:
Sex:
Patient’s or Parent’s Employer:
Work Phone:
Business Address:
City:
State:
Zip:
Who is financially responsible for this bill?
Phone Number:
Whom may we thank for referring you?
Name of Emergency contact:
Phone Number:
Family Physician:
Phone Number:

INSURANCE INFORMATION:

Name of Subscriber:
Birth Date:
SSN:
Name of Employer:
Insurance Company Name:
Group #:
Claims Address:
City:
State:
Zip:
Phone Number

GENERAL INFORMATION:

What is the reason for today’s visit?
Do you love your smile?
Is there anything you would like to change?
When was your last cleaning?
Why did you leave your last dentist?

MEDICAL HISTORY:

Are you currently under the care of a physician?
Please Explain:
Are you currently taking medications:
If YES, please list:
Are you allergic to:
Explain:
(Female Patients) Are you pregnant?
If Yes, due date?

Do you have or ever had?

Anemia Arthritis Artificial Joints Asthma AIDS/HIV Blood Disease/Disorder Diabetes Dizziness
Epilepsy Fainting Glaucoma Hay Fever Head Injuries Heart Murmurs Heart Attack Heart Problems
Hepatitis A B C High Blood Pressure Jaundice Kidney Disease Liver Disease Low Blood Pressure
Mental Disorders Nervous Disorders Pacemaker Currently Pregnant Rheumatic Fever Rheumatism
Radiation Treatment Respiratory Trouble Sinus Problems Stroke Sexually Transmitted Disease
Tuberculosis Tumors Ulcers Codeine Allergy Sulfa Allergy Penicillin Allergy Taking Blood Thinners
Other

I authorize and give consent to perform dental services agreed between doctor and patient and/or parent or guardian to be necessary or advisable including the use of local anesthesia and other medication as indicated. I certify to the above statements regarding my medical condition.

I understand and agree that I am ultimately responsible for the balance on my account for any professional service rendered, regardless of insurance status. I have read all the information on this sheet and have completed the above answers. I certify this information is true and correct to the best of my knowledge. I will notify you of any changes in my health status or changes to the above information.

Signature:

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Date:
Parent of Guardian (if a minor)
Date:

APPOINTMENT POLICY

Dr. Keanna is committed to providing quality dental care for his patients. We realize the importance of your time and do everything possible to keep you from waiting. We also ask that you value the time of Dr. Keanna and his staff. Appointment reminder calls are done only as a courtesy. Our office requires that if you need to cancel or reschedule an appointment, that you kindly give us two business days’ notice for appointments one hour or longer. If you have to cancel or reschedule a long or surgical appointment we will require 5 business days’ notice. When cancelling on our message machine or with our answering service, messages left over the weekend cancelling for a Monday are not acceptable. Please note that the office hours are 9AM-3PM Monday-Thursday, these are acceptable time to reach us regarding your appointment. The fees for failed or missed appointments are as follows: Appointment scheduled with Dr.Keanna are 10% of the total cost of the appointment. Hygiene appointments improperly rescheduled or cancelled without proper notice will result in a $50.00 non-refundable fee and a pre-payment is required for the next scheduled hygiene appointment made.

Signature:

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Date:

HIPPA ACKNOWLEDGEMENT

I, have received/read a copy of this office’s Notice of Privacy Practices.
Print Name:
Signature:

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Date:

As a condition of treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from patients for the costs incurred in their care. Financial responsibility on the part of each patient must be determined before treatment.

All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed unless other arrangements are made.

Patients with dental insurance understand that all dental services are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patient’s insurance forms or assist in making collections from insurance companies and will credit any collections to the patient’s account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company. I understand that this office does not file secondary insurance claims.

A service charge of 1% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied.

I understand that any fee estimate for this dental care can only be extended for a period of six months from the date of the patient examination.

In consideration for the professional services rendered to me by this practice, I agree to pay for the charges for the services at the time of treatment, or within five (5) days of billing if credit is extended. I further agree that the charges for services shall be as billed unless objected to, by me, in writing, within the time payment is due. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder.

I grant my permission to you or your assignee, to telephone me to discuss this statement or my treatment.

I have read the above conditions of treatment and payment and agree to their content.

Signature of patient, parent, or guardian (responsible party):

Print Full Name:
Date
Signature:

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Relationship to Patient:

For future office use:

Patient Name:
Anemia Arthritis Artificial Joints Asthma AIDS/HIV Blood Disease/Disorder Diabetes Dizziness
Epilepsy Fainting Glaucoma Hay Fever Head Injuries Heart Murmurs Heart Attack Heart Problems
Hepatitis A B C High Blood Pressure Jaundice Kidney Disease Liver Disease Low Blood Pressure
Mental Disorders Nervous Disorders Pacemaker Currently Pregnant Rheumatic Fever Rheumatism
Radiation Treatment Respiratory Trouble Sinus Problems Stroke Sexually Transmitted Disease
Tuberculosis Tumors Ulcers Codeine Allergy Sulfa Allergy Penicillin Allergy Taking Blood Thinners
Other
Date of Change: