New Patient Forms

CONFIDENTIAL INFORMATION QUESTIONNAIRE
PATIENT'S LEGAL NAME *

First Name Middle Initial Last Name
DATE OF BIRTH *
SEX *
PREFER TO BE CALLED
SSN *
HOME PHONE # *

Area Code Phone Number
CELL PHONE #

Area Code Phone Number
PATIENT'S ADDRESS *
EMAIL
Marital Status

Single Married Widowed Divorced Under age 18
PATIENT'S / GUARDIAN'S EMPLOYER
OCCUPATION
WORK ADDRESS
WORK PHONE #

Area Code Phone Number
SPOUSE'S NAME

First Name Last Name
SPOUSE'S EMPLOYER
OCCUPATION
SPOUSE'S WORK ADDRESS
WORK PHONE #

Area Code Phone Number
OTHER FAMILY MEMBERS THAT ARE PATIENTS HERE
WHO CAN WE THANK FOR REFERRING YOU TO OUR OFFICE?
EMERGENCY CONTACT INFORMATION

PERSON WE MAY CONTACT IN CASE OF AN EMERGENCY (OTHER THAN YOUR FAMILY HOME)
Name *

First Name Last Name
RELATIONSHIP *
HOME PHONE # *

Area Code Phone Number
WORK PHONE #

Area Code Phone Number
CELL PHONE #

Area Code Phone Number
REQUEST FOR CONFIDENTIAL COMMUNICATION

AS MY DENTAL CARE PROVIDER, YOU MAY DO THE FOLLOWING WITH MY PERMISSION:
Contact me at home *

YES NO
Contact me via cell phone *

YES NO
Contact me at work *

YES NO
Contact me via email *

YES NO
Leave messages on my home voicemail / answering machine *

YES NO
Leave messages on my cell phone voicemail *

YES NO
Leave messages on my work voicemail / answering machine *

YES NO
PHARMACY
PHARMACY NAME
PHONE NUMBER

Area Code Phone Number
INSURANCE AND FINANCIAL INFORMATION
INSURANCE COVERAGE *

YES NO
INSURANCE COMPANY NAME *
INSURANCE ADDRESS
INSURANCE PHONE

Area Code Phone Number
SUBSCRIBER'S NAME *
SUBSCRIBER'S BIRTHDAY *
PATIENT'S RELATIONSHIP TO SUBSCRIBER *

SELF SPOUSE DEPENDENT
GROUP/PROGRAM NUMBER *
SUBSCRIBER ID *
EMPLOYER (IF DIFFERENT FROM ABOVE)
EMPLOYER'S ADDRESS
SECONDARY COVERAGE

YES NO
INSURANCE COMPANY NAME
INSURANCE ADDRESS
INSURANCE PHONE

Area Code Phone Number
SUBSCRIBER'S NAME
SUBSCRIBER'S BIRTHDAY
PATIENT'S RELATIONSHIP TO SUBSCRIBER

SELF SPOUSE DEPENDENT
GROUP/PROGRAM NUMBER
SUBSCRIBER ID
EMPLOYER (IF DIFFERENT FROM ABOVE)
EMPLOYER'S ADDRESS
RELEASE INFORMATION

YOU MAY DISCUSS MY HEALTHCARE WITH
Health Care Providers *

YES NO
Insurance Companies *

YES NO
Others (Please List):
CONFIRMATIONS

DO YOU PREFER A CONFIRMATION CALL?
No, it is unnecessary Yes, it is a helpful reminder
ASSIGNMENT AND RELEASE
I hereby authorize my insurance benefits to be paid directly to the dentists. I am financially responsible for any balances due and authorize the dentists to release any information for this claim. I authorize that my records can be used by the doctor if he so determines. In consideration of the services rendered to me by this dental office, I am obligated to pay said office in accordance with its credit terms and policy.

I consent to the making of videotapes, photographs, and x-rays before, during and after treatment, and to use of the same by the doctor in scientific papers or demonstrations.

I certify that I have read or had read to me the contents of this form and do realize the risks and limitations involved.
SIGNATURE - PATIENT/GUARDIAN - Please draw your signature using your finger if on a mobile device or mouse cursor if on a computer. Your full signature must be included for your form to be valid. *

Clear
Date

Month Day Year
Date
WITNESS SIGNATURE

Clear
Date

Month Day Year
Date
MEDICAL HISTORY
Patient Name: *

First Name Last Name
Birth Date: *
Today's Date:

Month Day Year
Date
What is your estimate of your overall general health? *

Excellent Good Fair Poor
Have you ever been hospitalized for an illness or injury? *

Yes No
If yes, please explain:
DO YOU HAVE OR HAVE YOU EVER HAD an allergic reaction to any of the following (select all that apply):

aspirin, ibuprofen, acetaminophen, codeine penicillin erythromycin tetracycline sulfa local anesthetic fluoride chlorhexidine (CHX) metals (nickel, gold, silver, etc) latex nuts fruit
DO YOU HAVE OR HAVE YOU EVER HAD (select all that apply):

heart problems or cardiac stent within the last six months history of infective endocarditis artificial heart valve, repaired heart defect (PFO) pacemaker or implantable defibrillator orthopedic implant (joint replacement) rheumatic or scarlet fever high or low blood pressure a stroke (taking blood thinners) anemia or other blood disorder prolonged bleeding due to a slight cut (INR > 3.5) pneumonia, emphysema, shortness of breath, sarcoidosis chronic ear infections, tuberculosis asthma breathing or sleep problems (i.e. sleep apnea, snoring, sinus) kidney disease liver disease jaundice thyroid, parathyroid disease, or calcium deficiency hormone deficiency high cholesterol or taking statin drugs diabetes stomach or duodenal ulcer digestive or eating disorders (celiac disease, gastric reflux) osteoporosis/osteopenia (taking bisphosphonates) arthritis autoimmune disease (rheumatoid arthritis, lupus, scleroderma) glaucoma contact lenses head or neck injuries epilepsy/convulsions (seizures) neurologic disorders (ADD/ADHD, prion disease) viral infections and cold sores any lumps or swelling in the mouth hives, skin rash, hay fever STI/STD/HPV hepatitis HIV/AIDS tumor, abnormal growth radiation therapy chemotherapy, immunosuppressive medication emotional difficulties psychiatric treatment antidepressant medication alcohol/recreational drug use
ARE YOU (select all that apply):

presently being treated for any other illnesses aware of a change in your health in the last 24 hours taking medication for weight management taking dietary supplements often exhausted or fatigued a smoker, smoked previously or use smokeless tobacco considered a touchy/sensitive person often unhappy or depressed taking birth control pills currently pregnant diagnosed with a prostate disorder
Did you answer yes to any of the questions above? *

Yes No
If yes, please explain:
Describe any past or current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment (i.e. Botox/Collagen injections):
Please list all medications, supplements and/or vitamins taken within the last two years and provide purpose in the comment:
Signature of Patient, Parent or Guardian: Please draw your signature using your finger if on a mobile device or mouse cursor if on a computer. Your full signature must be included for your form to be valid. *

Clear
Date

Month Day Year
Date
DENTAL HISTORY
Name: *

First Name Last Name
Nickname:
Age: *
How would you rate the condition of your mouth? *

Excellent Good Fair Poor
Referred by:
Previous dentist: *
How long have you been a patient? *
Months/Years
Date of most recent dental exam

Month Day Year
Date
Date of most recent x-rays

Month Day Year
Date
Date of most recent treatment (other than a cleaning)

Month Day Year
Date
I routinely see my dentist every: *

3 months 4 months 6 months 12 months Not routinely
WHAT IS YOUR IMMEDIATE CONCERN?
PLEASE ANSWER YES OR NO TO THE FOLLOWING:
PERSONAL HISTORY
1. Are you fearful of dental treatment? *

YES NO
How fearful, on a scale of 1 (least) to 10 (most)?
2. Have you had an unfavorable dental experience? *

YES NO
3. Have you ever had complications from past dental treatment? *

YES NO
4. Have you ever had trouble getting numb or had any reactions to local anesthetic? *

YES NO
5. Did you ever have braces, orthodontic treatment or had your bite adjusted? *

YES NO
6. Have you had any teeth removed or missing teeth that never developed? *

YES NO
GUM AND BONE
7. Do your gums bleed or are they painful when brushing or flossing? *

YES NO
8. Have you ever been treated for gum disease or been told you have lost bone around your teeth? *

YES NO
9. Have you ever noticed an unpleasant taste or odor in your mouth? *

YES NO
10. Is there anyone with a history of periodontal disease in your family? *

YES NO
11. Have you ever experienced gum recession? *

YES NO
12. Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple? *

YES NO
13. Have you experienced a burning or painful sensation in your mouth not related to your teeth? *

YES NO
TOOTH STRUCTURE
14. Have you had any cavities within in the past 3 years? *

YES NO
15. Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food? *

YES NO
16. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth? *

YES NO
17. Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth? *

YES NO
18. Do you have grooves or notches on your teeth near the gum line? *

YES NO
19. Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling? *

YES NO
20. Do you frequently get food caught between any teeth? *

YES NO
BITE AND JAW JOINT
21. Do you have any problems with your jaw joint? (Pain, sounds, limited opening, locking, popping) *

YES NO
22. Do you feel like your lower jaw is being pushed back when you bite your teeth together? *

YES NO
23. Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods? *

YES NO
24. Have your teeth changed in the last 5 years, become shorter, thinner or worn? *

YES NO
25. Are your teeth becoming more crooked, crowded or overlapped? *

YES NO
26. Are your teeth developing spaces or becoming more loose? *

YES NO
27. Do you have to make more than one bite, squeeze, or shift your jaw to make your teeth fit together? *

YES NO
28. Do you place your tongue between your teeth or close your teeth against your tongue? *

YES NO
29. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits? *

YES NO
30. Do you clench your teeth in the daytime or make them sore? *

YES NO
31. Do you have any problems with sleep (i.e. restlessness), wake up with a headache or an awareness of your teeth? *

YES NO
32. Do you wear or have you ever worn a bite appliance? *

YES NO
SMILE CHARACTERISTICS
33. Is there anything about the appearance of your teeth that you would like to change? *

YES NO
34. Have you ever whitened (bleached) your teeth? *

YES NO
35. Have you ever felt uncomfortable or self conscious about the appearance of your teeth? *

YES NO
36. Have you been disappointed with the appearance of previous dental work? *

YES NO
Patient's Signature - Please draw your signature using your finger if on a mobile device or mouse cursor if on a computer. Your full signature must be included for your form to be valid. *

Clear
Date

Month Day Year
Date
Financial Policy
This is an agreement between Drake Dental, as creditor and the Patient/Debtor named on this form. By executing this agreement, you are agreeing to pay for all services that are received. Payment in full for your portion is expected at the time of service or a $25 handling fee will be added. All insurance co-payments and deductibles are expected at the time of service.

Payment Options
1. We gladly accept cash, Visa/Mastercard, or check (for existing patients with established payment history). There is a $35 fee for any returned checks returned from the bank.
2. For treatment involving laboratory fees (crowns, bridges, dentures, implants, etc.) you may choose to pay 50% when you scheduled the appointment and 50% at your actual appointment.
3. If you are in need of extended financing, we are pleased to offer a third party financing option through Care Credit, for those who qualify.
Insurance: Your dental benefits (insurance) are based upon a contract made between your employer and an insurance company. We are not a party to this contract in most cases. As a courtesy, we bill your insurance company. We currently accept all private care insurance plans. This means that we work with literally hundreds of companies. Although we can maintain computerized history of payment by a given company, they do change; therefore it is impossible to give you a guaranteed quote at the time of service. We estimate your portion based on the most up-to-date information we have, but it is ONLY AN ESTIMATE. If you would like a more accurate insurance benefit estimate, we will be happy to file a "pre-treatment authorization" with your insurance company prior to treatment. This does delay treatment but will give you a better estimate of the out of pocket figure you may require. Please be aware that this is still not a guarantee of payment from your insurance. If your insurance does not pay within 90 days, Drake Dental reserves the right to request payment in full for services from you and let you collect the insurance funds that are due to you. This is rare, but it is important that you recognize that the insurance benefit you have is a legal contract between YOU and your insurance company. Our office is not and cannot be part of that legal contract. Ultimately, you are responsible for all charges incurred in our office.

Finance Charge: A finance charge will be imposed on balances not paid within 30 days of the time the item was added to the account. The FINANCE CHARGE will be computed at the rate of one and one half percent (1.5%) per month or an ANNUAL PERCENTAGE rate of eighteen percent (18%). The finance charge on your account is computed by applying the periodic rate (1%) to the overdue balance of your account. The "overdue balance" of your account is calculated by taking the balance owed thirty (30) days ago, and then subtracting any payments or credits applied to the account during that time. The minimum finance charge is $0.50.

Credit History: You give us permission to check your credit and employment history and to answer questions about your credit experience with us. We have the option to report your account status to any credit reporting agency such as a credit bureau.

Broken Appointment Fee: Patients who do not show up on time for an appointment or cancel with less than 2 business day's notice will be charged a fee. This fee must be paid before a new appointment is scheduled. Patients with three missed appointments will be asked to transfer their records to another doctor.
Patient's Name: *
Responsible Party (if not the patient):
Patient's Signature - Please draw your signature using your finger if on a mobile device or mouse cursor if on a computer. Your full signature must be included for your form to be valid. *

Clear
Date

Month Day Year
Date
465 S. Drake Rd., Kalamazoo, MI 49009

(269) 344-7222
Acknowledgement of receipt of Notice of Privacy Practices
*You may refuse to sign the acknowledgement*
Name: *
Signature: Please draw your signature using your finger if on a mobile device or mouse cursor if on a computer. Your full signature must be included for your form to be valid.s

Clear
Date:

Month Day Year
Date
For Office Use Only

We attemped to obtain acknowledgement of receipt of our Notice of Privacy Practice, but acknowledgement could not be obtained because:

[ ] Individual refused to sign

[ ] Communication barriers prohibited obtaining the acknowledgement

[ ] An emergency situation prevented us from obtaining acknowledgement

[ ] Other (Please specify below)
COVID‐19 Patient Screening
Patient Name

First Name Last Name

COVID-19 Screening *

	YES	NO
Have you had a confirmed or suspected case of COVID-19?
Have you had contact with or cared for someone with a confirmed or suspected diagnosis of COVID-19 in the last 14 days?
Are you currently experiencing or have you experienced any of the following flu-like symptoms within the last week: Fever, cough, sore throat, runny nose, respiratory illness, difficulty breathing, gastrointestinal upset or any other unusual symptoms (like loss of taste or smell)?
Do you suspect yourself, any close family member or roommate of having early flu-like symptoms?
Have you done any significant traveling (by plane or mass transit) or attended a mass gathering (conference, concert, etc) within the last 14 days?
Have you been in close contact with someone who has returned from significant traveling (by plane or mass transit) or attended a mass gathering (conference, concert, etc) in the last 14 days?
Are you over the age of 65?**
Do you have heart disease, lung disease, kidney disease, diabetes or any other auto-immune disorder or health issue that compromises your immune system?**

**If you answered YES to questions #7 or #8, you are at an increased risk of more serious complications if you contract COVID-19. We are still happy to see you and take care of you but want to make sure you are willing to assume this increased risk. Do you feel comfortable keeping your appointment?

Yes No
Which of our offices should receive your forms? *

Portage office Kalamazoo office
Should be Empty:

CONFIDENTIAL INFORMATION QUESTIONNAIRE

EMERGENCY CONTACT INFORMATION

REQUEST FOR CONFIDENTIAL COMMUNICATION

PHARMACY

INSURANCE AND FINANCIAL INFORMATION

RELEASE INFORMATION

CONFIRMATIONS

ASSIGNMENT AND RELEASE