chipsdental.com - General Patient Info

Patient Name *

Title First Name Middle Name Last Name

Preferred Name

Patient Gender *

Spouse's Name

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Patient Birth Date *

Month Day Year

Home Phone

Area Code Phone Number

Work Phone

Area Code Phone Number

Cell Phone

Area Code Phone Number

Patient E-Mail *

Employer

Occupation

Are you a full-time student at a college?

Yes No

If yes, name of college

Marital Status: *

Single Married Divorced Widowed Separated Domestic Partner

How did you hear about our office?

Please check your preferred method of contact for appointment confirmation:

E-MAIL CELL PHONE WORK PHONE HOME PHONE

Primary Dental Guarantor

Relationship to Patient

Guarantor's DOB

Guarantor ID

Group Number

Guarantor Employer

Insurance Company Name

Insurance Company Address

Insurance Company Phone

Area Code Phone Number

Secondary Guarantor Name

Relationship to Patient

Guarantor DOB

Guarantor ID

Group Number

Guarantor Employer

Insurance Company Name

Insurance Company Address

Insurance Company Phone

Area Code Phone Number

Name *

Relationship

Phone

Area Code Phone Number

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Do you have a personal physician? *

Yes No

Physician's Name

Physician's Phone

Area Code Phone Number

Are you currently under the care of a physician? *

Yes No

Date of Last Visit

If yes, please explain

Height

Blood Pressure

Weight

Heart Rate

Are you taking any medication? *

Yes No

If yes, please list each one

Do you use tobacco in any form? *

Yes No

If yes, please list type and frequency of use

Do you have any artificial joints or implants? *

Yes No

If yes, please list along with date of surgery

Do you have any of these conditions? *

	Yes	No
Abnormal Bleeding
Alcohol Abuse
Allergies
Anemia
Angina Pectoris
Arthritis
Artificial Heart Valve
Asthma
Blood Transfusion
Cancer
Chemotherapy
Congenital Heart Defect
Diabetes
Difficulty Breathing
Drug Abuse
Emphysema
Epilepsy
Facial Surgery
Fainting Spells
Fever Blisters
Frequent Headaches
Glaucoma
HIV + AIDS
Heart Attack
Heart Murmur
Heart Surgery
Hemophilia
Hepatitis A
Hepatitis B
Hepatitis C
High Blood Pressure
Joint Replacement
Kidney Problems
Liver Disease
Mitral Valve Prolapse
Pace Maker
Psychiatric Care
Radiation Therapy
Rheumatic Fever
Seizures
Sexually Transmitted Disease
Shingles
Sickle Cell Disease
Sinus Problems
Stroke
Thyroid Problems
Tuberculosis
Ulcers
Yellow Jaundice
None of the Above

Do you have any of these allergies? *

	Yes	No
Aspirin
Codeine
Dental Anesthetics
Erythromycin
Jewelry
Latex
Metals
Penicillin
Tetracycline
None of the Above

Other Allergies:

If Female, do you have any of these conditions?

	Yes	No
Are you taking birth control pills?
Are you nursing?
Are you pregnant?

If you are pregnant, how many weeks?

Do you have any disease, condition or problem that you feel we should know about? If so, please describe

How may we help you today?

Your current dental health is *

Good Fair Poor

Frequency of check-ups:

Date of Last x-rays

Date of your last visit

When was your last cleaning?

Summarize your previous dental care:

What is your description of any current problems:

What changes in your dental appearance would you like to see, if any?

Please answer the following: *

	Yes	No
Bite lips, cheeks, fingernail,etc.
Clench teeth when awake
Grind teeth when asleep
Have any sensitive teeth (hot, cold and /or pressure)
Have bleeding or sore gums
Have frequent headaches
Have pain in jaw joint
Have limited jaw opening
Hear sounds in jaw joint
Hear ringing in ears
Have speech problems
Mouth breathe when awake or asleep
Play a musical instrument
Rest on chin
Thrust tongue when swallowing
Were a partial or complete denture
Have any unhealed injuries or inflamed areas in or around mouth
Any growths or sores in mouth
Any reactions or allergic symptoms to novocaine
Any difficult extraction in past
Prolonged bleeding following extractions in past
None of the above

Have you ( or your child) ever: *

	Yes	No
Been informed of extra teeth?
Been informed of missing teeth
Had previous orthodontic care or consulted and Orthodontist
Had an injury to chin, face, head, moth or teeth
Had any baby teeth extracted
Had any second teeth extracted
Sucked a pacifier
Sucked finger(s)
Sucked thumb
Had you ever had instruction on the correct method of brushing your teeth and gum care
None of the above

If yes to any of the above, please describe -- when, for what, by whom, from whom, how often, what type, until what age, etc.

How many times do you:

floss/week

brush/day

Please answer the following *

	Yes	No
Do you take fluoride supplements?
Have you ever had a serious/difficult problem with any previous dental work?
Have you ever had any unfavorable dental experiences?
Are you apprehensive about dental treatment?
Do you gag easily?
Would you like whiter teeth?
Would you like straighter teeth?
Do you have any spaces between teeth that you do not like?
None of the above

If there was one thing you could change about your smile, what would it be?

Type of tooth brush

Type of toothpaste

How can we accommodate you better during your dental visit?

Is there any specific service and/or concern you would like to inquire about?

Thank you for choosing Chips Dental Associates, LLC. Our primary mission is to deliver the best and most comprehensive dental care available. An important part of the mission is making the cost of optimal care as easy and manageable for our patients as possible by offering several payment options.

Payment Options: You can choose from:

- Cash, Check, Visa, MasterCard, American Express or Discover Card We offer a 5% courtesy accounting adjustment to patients who pay for their treatment with cash or check prior to completion of care for treatment plans of $500 or more.

- Convenient Monthly Payment Options (subject to credit approval) from CareCredit or the Healthcare Credit Card. This allows you to pay over time with no annual fees or pre-payment penalties.

Please note: Chips Dental Associates, LLC requires payment prior to the completion of your treatment. If you choose to discontinue care before treatment is complete, your refund will be determined upon review of your case.

A 50% deposit is required to secure your initial treatment appointment.

For patients with dental insurance, we are happy to work with your carrier to maximize your benefit and directly bill them for reimbursement for your treatment. However, If we do not receive payment from your Insurance carrier within 60 days, you will be responsible for payment of your treatment f􀀇ees and collection of your benefits directly from your Insurance carrier.

A fee of $75 is charged for patients who miss or cancel more than 1 time in a calendar year without 48-hour notice.

Chips Dental Associates, LLC charges $30 for returned checks.

If you have any questions, please do not hesitate to ask. We are here to help you get the dentistry you want or need.

I, the undersigned, certify that I (or my dependent) have the insurance coverage indicated on this form and assign directly to Chips Dental Associates, LLC, 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 insurances. 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. I consent to the diagnostic procedures and treatment by the dentist necessary for proper dental care. I understand that the information I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.

I have read the above Financial Policy, Assignment and Release

I have read and will abide by the Policy, Assignment and Release above I have not read the Financial Policy, Assignment and Release Statements I do not agree to abide by the Policy, Assignment and Release above

Responsible Party Signature: ___________________________________ Date:______________

(The signature above will be physically signed when at dental office.)

General Patient Information

Insurance - Primary

Insurance - Secondary

Nearest relative not living with you:

Medical History

Dental History

Our Financial Policy, Assignment and Release