Thank you for selecting our dental healthcare team!
We will strive to provide you with the best possible dental care.
To help us meet all your dental healthcare needs, please fill out this form.
If you have any questions or need assistance, please ask us!
  • PATIENT INFORMATION
  • Date
  • Name:
  • Birthdate:
  • Sex:
  • Male Female
  • Address:
  • City:
  • State:
  • Zip:
  • Child Single Married Divorced Widowed Separated
  • Home Phone:
  • Cell Phone:
  • Work Phone:
  • Best Time to Call:
  • Morning Afternoon
  • Preferred Contact Method:
  • Phone Call Text message Email
  • Email:
  • If student name of school:
  • City:
  • State:
  • Full time Part Time
  • Employer:
  • Address:
  • Spouse/Parent/Guardian's Name:
  • Number:
  • Whom may we thank for referring you?
  • Person to contact in case of emergency:
  • Phone:
  • Relationship:
  • RESPONSIBLE PARTY
  • Name of Person
    Responsible for this account:
  • Relationship to Patient:
  • Address:
  • Home Phone:
  • Birthdate:
  • Employer:
  • Currently a patient in the office?
  • Yes No
  • INSURANCE INFORMATION
  • Name of Insured:
  • Relationship to Patient:
  • Birthdate:
  • Social Security #
  • Date Employed:
  • Employer:
  • Phone Number:
  • Employer Address:
  • City:
  • State:
  • ZIP:
  • Insurance Company:
  • Group #:
  • Group Name:
  • Address:
  • City:
  • State:
  • ZIP:
  • ADDITIONAL INSURANCE
  • Name of Insured:
  • Relationship to Patient:
  • Birthdate:
  • Social Security #
  • Date Employed:
  • Employer:
  • Phone Number:
  • Insurance Company:
  • Group #:
  • Group Name:
  • Address:
  • City:
  • State:
  • ZIP:

  • Medical History Although dental personnel primarily treat the area 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.
  • Name:
  • Phone:
  • Date of last medical exam:
  • What was the exam for?
  • Current Physician:
    • Yes No
      Have you ever been hospitalized or had a major operation?
      Are you under the care of a physician?
      Have you ever had a serious head or neck injury?
      Are you taking any medications or supplements?
    • If yes, please list the medication, dose, & how often:
    • Do you take, or have you taken Phen-Fen or Redux?
      Have you ever taken Fosamax, Boniva, Actonel, or any other medications containing bisphosphonates?
      Are you on a special diet?
      Do you use Tobacco?
      Do you use controlled substances?
    • Women
    • Yes No
      Are you pregnant or trying to get pregnant?
      Are you taking contraceptives?
      Are you Nursing?
    • Are you allergic to any of the following?
    • Aspirin
    • Metal
    • Penicillin
    • Latex
    • Local Anesthetics
    • Sulfa Drugs
    • Acrylic
    • Other
    • :
    • Codeine
    • NONE
    • Food Allergies
  • CHECKED ALL THAT APPLY:
  • FAMILY HISTORY UNKNOWN?
  • Yes No
    • Yes No
      Acid Reflux
      AIDS\HIV Positive
      Alzheimer's Disease
      Anaphylaxis
      Anemia
      Angina
      Arthritis\Gout
      Artificial Heart Valve
      Artificial Joint:
    • What Joint?    
    • When?    
    • Asthma
      Blood Disease
      Blood Transfusion
      Breathing Problem
      Bruise Easily
      Cancer
    • Type?    
    • Chemotherapy
    • When?    
    • Chest Pains
      Cold Sores\Fever Blisters
      Congenital Heart Disorder
      Convulsions
      Cortisone Medicine
      Diabetes
      Drug Addiction
      Dry Mouth
      Easily Winded
    • Yes No
      Emphysema
      Epilepsy\Seizures
      Excessive Bleeding
      Excessive Thirst
      Fainting Spells\Dizziness
      Frequent Cough
      Frequent Diarrhea
      Frequent Headaches
      Genital Herpes
      Glaucoma
      Hay Fever
      Heart Attack\Failure
      Heart Murmur
      Heart Pace Maker
      Heart Trouble\Disease
      Hemophilia
      Hepatitis A
      Hepatitis B or C
      Herpes
      High Blood Pressure
      High Cholesterol
      Hives or Rash
      Hypoglycemia
      Inflammatory Disease
    • Type?    
    • Irregular Heartbeat
      Kidney Problems
      Leukemia
      Liver Disease
    • Yes No
      Low Blood Pressure
      Lung Disease
      Mitral Val. Prolapse
      Osteoporosis
      Jaw Pain
      Parathyroid Disease
      Psychiatric Care
      Radiation Treatments
    • When?    
    • Recent Weight Loss
      Renal Dialysis
      Rheumatic Fever
      Scarlet Fever
      Shingles
      Sickle Cell Disease
      Sinus Trouble
      Sleep Apnea
      Do you wear a c-pap?
      Spina Bifida
      Stomach Disease
      Stroke
      Swelling of Limbs
      Thyroid Disease
      Tonsillitis
      Tuberculosis
      Tumors or Growths
      Ulcers
      Venereal Disease
      Yellow Jaundice
  • HAVE YOU EVER HAD ANY SERIOUS ILLNESS NOT LISTED ABOVE?
  • Yes No
  • If yes, please explain:
  • FAMILY HISTORY UNKNOWN?
  • Yes No
  • 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 the medical status.
  • Signature of Patient, Parent, or Guardian:
  • Date:
  • Shady Spring Dental Care
    Consent for Treatment/Financial Agreement
  • Consent for treatment:
  • The undersigned hereby authorizes the Doctor to take x-rays, study models, photographs, or any other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of the patient’s dental needs. I also authorize the Doctor to perform any and all forms of treatment, medication, and therapy that may be indicated in connection with my treatment and further authorize and consent that the Doctorchoose and employ such assistance as deemed fit. I also understand that the use of anesthetic agents embodies a certain risk. By signing below,you consent to treatment at this office and any other satellite office under common ownership. This consent is continuing and will remain fully effective until it is revoked by you in writing.
  • Patient Name:
  • Date:
  • Patient/Guardian:
  • Date:
  • Financial Agreement:
  • I understand that responsibility for payment for the dental services provided for myself/family members is mine, due and payable at the time of service. I further understand that a 1.5 % finance charge will be added to any balance over 90 days. We will bill your insurance as a courtesy to you, but we cannot guarantee benefits or payment from them. Your dental insurance policy is a contract between you, your employer and your insurance company. It is your responsibility to thoroughly understand the coverages and exceptions of your policy and to provide us accurate information. We will do our best to assist you with your plan and maximize your benefits. A parent or legal guardian must accompany a child under the age of 18 for dental treatment. The parent that brings the child in is responsible for payment. In the event of default, I promise to pay legal interest on the indebtedness, together with such collection costs and attorney fees that may be required for collection of this note.
  • Patient Name:
  • Date:
  • Patient/Guardian:
  • Date:
  • Confirmation/Cancellation Agreement
  • Our scheduling team makes every effort to schedule your treatment at a time that is most convenient for you. When your dental needs are diagnosed, if left untreated over time, they may get worse. Therefore, it is very important that you keep your appointment as scheduled. Our patients understand and appreciate our confirmation/cancellation agreement and the positive effects it has on our practice. It allows us to best treat our patients in a timely manner.
  • In order to hold an appointment for you we do require confirmation. You will have the opportunity to confirm your appointment with us up to 14 days prior by text, email or phone call, whichever you prefer. We request confirmation at least 3 days before the scheduled appointment. If we do not receive confirmation, you will forfeit your appointment, and you will need to reschedule by calling our scheduling team.
  • Shady Spring Dental Care is committed to improving your oral health. We understand that situations arise that may require you to change an appointment; however, we request 48-hour notice, except in the case of emergencies. If you need to make an appointment change, our agreement concerning cancelled or failed appointments is as follows:
  • A patient with an appointment must call at least 48 hours in advance prior to canceling or rescheduling his or her appointment. A $40 fee for broken appointments violating this agreement may be incurred.
  • After the THIRD cancellation violating this policy within a 6-month period, we will provide treatment for 30 days on an emergency-only basis. At that time, we will give you an opportunity to find another dental office to take care of your dental needs.
  • I, understand and agree to this Policy.
  • Signature
  • Date:
  • Signature of Witness
  • Date:
  • HIPAA Patient Consent Form
  • I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
  • Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
  • Obtain payment from third-party payers.
  • Conduct normal healthcare operations such as quality assessments and physician certifications.
  • I have been informed by you of your Notice of Privacy Practicescontaining a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practicespriorto signing this consent. I understand that this organization has the right to change the Notice of Privacy Practicesfrom time to time and that I may contact this organization at any time to obtain a current copy of the Noticeof Privacy Practices.
  • I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or health care operations. I also understandthat you are not required to agree to my requested restrictions, but if you do agree, then you are bound to abide by such restrictions.
  • I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.
  • Patient Name:
  • Signature:
  • Relationship to Patient:
  • Date:
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