New Patient Forms

Patient name:

DOB:

Age:

Address:

Email Address:

Martial Status:

Phone Number:

Social Security #:

Emergency Contact:

Employer:

How Were You Referred?

Previous Dentist’s:

Any Dental Concerns?

Date of Last Exam/X-Rays:

DENTAL HISTORY:

Responsible Party:

First Name

Last Name

Relation:

DOB:

Social & ID#:

Employer:

Name of Insurance:

Phone #:

Group#:

Secondary Insurance? Yes No

If Yes, Responsible Party:

Last Name

First Name

DOB:

Social & ID#:

Employer:

Name of Insurance:

Phone #:

Group#:

By signing below, I authorize my insurance company to pay the dentist all insurance benefits due and payable. I authorize my Dentist to use of my electronic signature on all insurance claim submissions, and to release all information necessary to secure the payment of benefits. I understand I am financially responsible for the entire cost of treatment in the event my dental insurance does not pay on a claim.

Patient Name (Print)

Signature (Parent/Guardian if Minor)

Date

Patient Name:

Nickname:

Age:

Name of Medical Doctor:

Specialty:

Date of Last Physical:

Reason:

Rate Your Overall Health: Excellent Good Fair Poor

Explain:

DO YOU HAVE OR HAVE HAD:

Hospitalization for illness/injury Yes No

Explain:

Allergic Reaction To:

Aspirin, Ibuprofen, Acetaminophen, Codeine Yes No

Osteoporosis/Osteopenia (taking bisphosphonates): Yes No

Penicillin Yes No

Arthritis, Rheumatoid Arthritis, Lupus: Yes No

Erythromycin Yes No

Glaucoma: Yes No

Tetracycline Yes No

Contact Lenses: Yes No

Sulfa Yes No

Head or Neck Injuries: Yes No

Local Anesthetic Yes No

Epilepsy, Convulsions (seizures): Yes No

Fluoride Yes No

Neurologic Disorders (ADD/ADHD, prion disease): Yes No

Metals (nickel, gold, silver) Yes No

Viral Infection/Cold Sores: Yes No

STI/STD: Yes No

Heart Problems/Cardiac Stent Placed in Last 6mo: Yes No

Hepatitis (type): Yes No

History of Infective Carditis: Yes No

HIV/AIDS: Yes No

Artificial Heart Valve/Repaired Heart Defect (PFO): Yes No

Tumor or Abnormal Growth: Yes No

APacemaker/Implantable Defibrillator: Yes No

Radiation Therapy: Yes No

Artificial Prosthesis (heart valve/joints): Yes No

Chemotherapy, Immunosuppressive: Yes No

Rheumatic/Scarlet Fever: Yes No

Emotional Problems: Yes No

High or Low Blood Pressure: Yes No

Psychiatric Treatment: Yes No

A Stroke (taking blood thinners?) Yes No

Antidepressant Medication: Yes No

Emphysema, Shortness of Breath, Sarcoidosis: Yes No

ARE YOU:

Tuberculosis, Measles, Chicken Pox: Yes No

Presently Being Treated for an Illness: Yes No

Kidney Disease: Yes No

Taking Medication for Weight Management (fen-phen) Yes No

Liver Disease: Yes No

Taking Dietary Supplements: Yes No

Jaundice: Yes No

Often Exhausted or Fatigued: Yes No

Thyroid, Parathyroid Disease, or Calcium Deficiency: Yes No

Experiencing Frequent Headaches: Yes No

Hormone Deficiency: Yes No

A Smoker, Smoked Previously, Use Smokeless Tobacco: Yes No

High Cholesterol or Taking Statin Drugs: Yes No

Considered a Touchy Person (over sensitive): Yes No

Diabetes (HbA1c= ): Yes No

Often Unhappy or Depressed: Yes No

Stomach or Duodenal Ulcer: Yes No

FEMALE – Taking Birth Control Pills: Yes No

Digestive Disorders (celiac disease, gastric reflux): Yes No

FEMALE – Pregnant: Yes No

MALE – Prostate Disorders: Yes No

Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment (botox, collagen injections):

LIST ALL MEDICATIONS, SUPPLEMENTS, VITAMINS CURRENTLY TAKING:

DRUG

REASON

DRUG

REASON

Patient Signature (Parent/Guardian if Minor)

Date

Doctor’s Signature

Date

PATIENT ACKNOWLEDGEMENT OF OFFICE POLICIES/PROCEDURES

______ WE ASK THAT YOU TURN OFFAND/OR DO NOT USE YOUR CELL PHONE WHILE IN THE OPERATORY. ALSO, PLEASE USE THE RESTROOM UPON ARRIVAL IF NEEDED, BEFORE BEING SEATED IN THE OPERATORY.

______ Proper dental care is only possible with your cooperation, which includes scheduling and returning for appointments. We will do our best to remind you, but it is ultimately your responsibility to keep up on your appointments. We ask that you arrive a few minutes prior to your scheduled appointment time, to allow time for paperwork, etc. We also ask that you give us 48-hours’ notice if you need to cancel and/or reschedule your appointment so we can make the necessary adjustments to the schedule to accommodate another patient. Failure to do so may result in a $60 charge and, in some cases, you may be charged 10% of the total fee for the treatment that was scheduled, as it is sometimes difficult to fill the schedule at the last minute. Please note: Your appointment time may occasionally be changed slightly and, if that is necessary, you will be notified and given a chance to respond if the request is not going to work with your schedule. We will require updates in your health history every six months, however, it is also your responsibility to notify us if there are any changes in the interim—this includes medications, operations, accidents, change in health, etc. Everything must be disclosed for your safety and, at times, we may need a medical clearance from your treating physician prior to any dental treatment being rendered.

______ FINANCIAL POLICY/PAYMENT: Your financial responsibility will be determined before treatment begins, and is due and payable, in full, at the time services are rendered—unless other arrangements have been made. This includes treatment for crowns, bridges, implants, veneers, dentures, & partial dentures- whether or not the final restoration has been delivered. If you have dental insurance, we will estimate your portion as close as possible with the information we are given by your insurance carrier. Please note: Your estimated portion is only an estimate, as we cannot guarantee what or if your insurance carrier will pay. If the claim for your treatment is denied for ANY reason, you will be responsible for the entire fee for the services rendered at our usual and customary fee. We offer a no-interest or extended (with interest) payment plan through Care Credit if you need financing. We accept Visa, Mastercard, American Express, and Discover (a $2 processing fee will apply to credit card transactions). Personal checks will be at our discretion and, if the check is returned, a minimum of $75 will assessed to your account and you may be liable for up to three times the amount of the check. Accounts 90 days or more past due are subject to collection and, if initiated, a $75 charge will be added to your balance and interest will begin accruing at a rate of 1.5% monthly. You will be liable for all costs incurred including attorney fees, court costs, collection fees, outside collection agency fees, lab fees, any interest accrued, fees for certified mail, staff time at $150/hour, and Doctor time at $350/half hour. You give South Bay Dental Esthetics permission to contact your employer to verify employment and insurance information if needed.

______¬ **In order to keep our patients and staff safe during the COVID-19 Epidemic, we are charging a $20 COVID Infection Control fee at each visit, as we installed state of th¬¬e art suction equipment in each operatory, which allows the doctor to safely remove droplets and aerosol particles created while providing treatment. The system is able to filter the blood, viruses, germs, fluids, & dust that would otherwise end up contaminating the operatory, clothes, and body. We have also put extra PPE (Personal Protective Equipment) in place¬¬¬.

______ Expect to have xrays taken at least once per year, as they are necessary for diagnostic purposes. Xrays may reveal a problem that is not able to be seen during a visual exam. Individual radiographs may also be needed at any given appointment, which will be determined by clinical signs and symptoms. Implant, Periodontal, and Adolescent patients may require more frequent xrays. Certain procedures also warrant additional xrays and dental carriers require submission of additional or specific xrays to process your claim. Keep in mind we use digital technology for the xrays, therefore, your exposure to radiation is very minimal. We follow the ALARA Principal (As Low As Reasonably Achievable) to maintain your exposure and safety.

______ HIPPA: You may inspect or copy the Protected Health Information we have on file for you. This information can also be revoked, with a written-signed request. **Please list all persons with whom we may discuss your Protected Health Information with, including parents/legal guardians if the patient is under 18:

______ Material Safety Data Sheets are available to you at your request, and are supplied by OSHA (Occupational Safety and Health Association). They cover the basics of the products you may be exposed to at your visit-they include, but are not limited to: ingredients, handling/storage, protection, and what to do in case of accidental exposure or adverse reaction.

COMMUNICATION: Please indicate one or more option(s) below as your preferred method of communication:

We may contact you at your home number

We may contact you on your cellular phone: Verbally Text Message

We may contact you at your place of business

We may send you email correspondence

Patient Name:

Patient (and/or legal guardian if a minor) Signature:

DENTAL SERVICE ARBITRATION AGREEMENT

ARTICLE1. IT'SUNDERSTOOD ANY DISPUTE ASTOMALPRACTICE, SUCHASANYDENTALSERVICES RENDEREDWEREUNNECESSARY, UNAUTHORIZED, IMPROPERLY, NEGLIGENTLY, OR INCOMPETENTLY RENDERED, WILL BE DETERMINED BY SUBMISSION TO ARBITRATIONASPROVIDEDBYCALIFORNIA LAW-NOTBYALAWSUITORCOURTPROCESSEXCEPTASCALIFORNIA LAWPROVIDESFOR JUDICIAL REVIEW OF ARBITRATION PROCEEDINGS. BOTH PARTIES ENTERING INTO THIS CONTRACT ARE GIVING UP THEIR CONSTITUTIONAL RIGHT TO HAVE SUCH DISPUTE DECIDED IN COURT BEFORE A JURY AND, INSTEAD, ARE ACCEPTING USE OF ARBITRATION.

ARTICLE 2. In the event of any claim, demand, controversy, or dispute involving personal injury, malpractice or any sort, by Patient, his/her dependents (whether or not minors), heirs at law, or personal representatives, against Doctor/Doctor's officers, directors, shareholders, agents, representatives, employees, successors in interests, or associates {"Affiliates")-agree in writing to be bound by the arbitration provisions of this agreement. THESOLEMETHODFORRESOLVINGSUCHDISPUTESHALLBEBYBINDINGARBITRATION ADMINISTERED BYTHEAMERICAN
ARBITRATION ASSOCIATION inaccordance with theCommercial Arbitration Rules of the American Arbitration Assoc. The parties hereby agree to submit their controversy to Arbitrator (dentist licensed in Ca.) Such Arbitration shall be acceptable to both parties. In the event the parties cannot agree upon a sole Arbitrator, each party shall pick an Arbitrator who is a dentist licensed in Ca. and the two Arbitrators shall pick a third dentist proceeding under the rules of the American Arbitration Assoc. Not withstanding the foregoing two additional arbitrators who are dentistsmay be added by the parties by agreement in writing to create an arbitration panel of three. It's agreed all parties relevant a full and complete settlement of any dispute subject to this agreementmay beintervened or joined.

ARTICLE 3. The prevailing party in any arbitration pursuant this agreement shall be awarded all costs, including reasonable attorney and arbitrator fees, in prosecuting or defending the claim-not lo exceed $5,000. If any action is undertaken to set aside or otherwise attack the binding arbitration award, the losing party shall bear prevailing costs.

ARTICLE 4. Any party initiating arbitration under this agreement shall file his/her petition on bond or cash surety in an amount equal to FiveHundred Dollars ($500), which shall provide security for attorney's fees etc. in the event themoving party shall not prevail.

ARTICLE 5. This agreement shall govern all future services rendered to Patient by Doctor and/or Affiliates. Execution of this agreement is a precondition to the furnishing of services byDoctor, butmay be rescinded with written notice by either party within 30 days of signature. After 30 days, this agreementmay be changed/revokedonly by written revocation signed by both parties.

ARTICLE 6. I understand each Dentist is an individual practitioner and is individually responsible for dental care rendered. I also understand no other
Dentist, other than treating Dentist, is responsible for my treatment.

ARTICLE 7. Doctor hereby agrees to render dental care and service to Patient. Patient agrees to pay Doctor promptly upon the rendering of a bill at current prevailing rates, or to corporate withDoctor in obtaining payment from third party payers.

ARTICLE8. Except the fact thatDoctor has indicated professional services will not be rendered toPatient unless agreement is excelled, Doctor has made no other receptions or statements (oral/written)to inducePatient to execute agreement.

ARTICLE A9. In the event any provision of this agreement shall be void/unenforceable for any reason whatsoever, such provision shall be stricken and of no force and effect.
The remaining provisions of this agreement, however, shall continue in full force and effect to the extent required, and shall bemodified to preserve their validity. This agreement is governed byCalifornia law.

ARTICLE10. RETROACTIVE EFFECT: The patient intends this agreement to cover all services rendered byDoctor, not only after the date it's signed (including, but not limited to, emergency treatment), but also before ii was signed. THIS IS A BINDING LEGAL DOCUMENTWHICHMAYHAVE AN IMPORTANT EFFECTONYOURLEGAL RIGHTS. CONSULT YOUR ATIORNEYWITHANYQUESTIONS YOUMAYHAVE.

By signing below, I acknowledge and agree to the above statement.

Patient Name (Print)

Patient Signature (Legal Guardian if Minor)