New Patient Online Form

Note: If you would like to print the form and fill it out by hand, please click here

Personal Information

Spouse Information

In Case of Emergency, who should we contact other than your spouse?

Dental Insurance Company #1

Dental Insurance Company #2

For the following questions, select yes or no, whichever applies. Your answers are for our records only and will be considered confidential. Please note during your initial visit you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health.

1. Are you in good health? If no, why?
2. Has there been any changes in your general health within the past year?
3. The date of my last physical exam was on:
4. Are you now under the care of a physician? If yes, why?
5. The name, address, and phone number of your physician(s) Is:
6. Have you had a serious illness, operation, or been hospitalized in the past 5 years?
7. Are you taking any medicine(s) including non-prescription Medicine?
8. Do you have or have you had any of the following (please check all that apply):

Women ONLY

1. Are you pregnant?

2. Are you nursing?

3. Are you taking birth control pills?

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPPA), 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 health & dental care operations such as quality assessments and physician's certifications.

I acknowledge that I can receive your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact Dental Health Associates at any time to obtain a current copy of the Notice of 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. In addition, I understand you are not required to agree to my requested restrictions.

1 + 1 =

Please answer the math problem above

Your information will remain strictly confidential.