Patient name:

DOB:
Age:
Address:
Email Address:
Who Do You Work For?
How Were You Referred?
Previous Dentist’s:
Martial Status:
Phone Number:
Social Security #:
Emergency Contact:
What Do You Do?
Any Dental Concerns?
Date of Last Exam/X-Rays:

DENTAL HISTORY:

Reaction to Local Anesthetic
Clench/Grind Teeth
Bleeding Gums
Difficulty Chewing
Nervous/Anxiety of Dental Work
Dry Mouth
Have Gum Disease (Periodontitis)
Hot/Cold Sensitivity
Premed Prior To Dental Work
Food Trapping
Bone Loss
Difficulty Swallowing
Bad Taste/Odor in Mouth
Trouble Getting Numb
Popping/Clicking of Jaw
Gum Recession
Snoring

Responsible Party:

First Name
Last Name

Relation:

DOB:
Social & ID#:
Employer:
Name of Insurance:
Phone #:
Group#:
Secondary Insurance?
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:
Explain:

DO YOU HAVE OR HAVE HAD:

Hospitalization for illness/injury
Explain:
Allergic Reaction To:
Aspirin, Ibuprofen, Acetaminophen, Codeine
Osteoporosis/Osteopenia (taking bisphosphonates):
Penicillin
Arthritis, Rheumatoid Arthritis, Lupus:
Erythromycin
Glaucoma:
Tetracycline
Contact Lenses:
Sulfa
Head or Neck Injuries:
Local Anesthetic
Epilepsy, Convulsions (seizures):
Fluoride
Neurologic Disorders (ADD/ADHD, prion disease):
Metals (nickel, gold, silver)
Viral Infection/Cold Sores:
Latex
Any Lumps or Swelling in Mouth:
Hives, Skin Rash, Hay Fever:
STI/STD:
Heart Problems/Cardiac Stent Placed in Last 6mo:
Hepatitis (type):
History of Infective Carditis:
HIV/AIDS:
Artificial Heart Valve/Repaired Heart Defect (PFO):
Tumor or Abnormal Growth:
APacemaker/Implantable Defibrillator:
Radiation Therapy:
Artificial Prosthesis (heart valve/joints):
Chemotherapy, Immunosuppressive:
Rheumatic/Scarlet Fever:
Emotional Problems:
High or Low Blood Pressure:
Psychiatric Treatment:
A Stroke (taking blood thinners?)
Antidepressant Medication:
Anemia or Other Blood Disorder:
Prolonged Bleeding (INR >3.5):
Alcohol/Street Drug Use:
Emphysema, Shortness of Breath, Sarcoidosis:
ARE YOU:
Tuberculosis, Measles, Chicken Pox:
Presently Being Treated for an Illness:
Asthma:
Breathing/Sleep Problems (sleep apnea, snoring):
Aware of a Change in Your Health in the last 24hrs
(fever, chills, new cough, diarrhea):
Kidney Disease:
Taking Medication for Weight Management (fen-phen)
Liver Disease:
Taking Dietary Supplements:
Jaundice:
Often Exhausted or Fatigued:
Thyroid, Parathyroid Disease, or Calcium Deficiency:
Experiencing Frequent Headaches:
Hormone Deficiency:
A Smoker, Smoked Previously, Use Smokeless Tobacco:
High Cholesterol or Taking Statin Drugs:
Considered a Touchy Person (over sensitive):
Diabetes (HbA1c= ):
Often Unhappy or Depressed:
Stomach or Duodenal Ulcer:
FEMALE – Taking Birth Control Pills:
Digestive Disorders (celiac disease, gastric reflux):
FEMALE – Pregnant:
MALE – Prostate Disorders:

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
______ **PLEASE USE THE RESTROOM (IF NEEDED), AS SOON AS YOU ARRIVE-BEFORE BEING SEATED IN THE OPERATORY
______ **PLEASE TURN OFF AND/OR DO NOT USE YOUR CELL PHONE WHILE IN THE OPERATORY.

______ APPOINTMENTS: 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, and 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 some reason, you will be responsible for the entire fee for the services rendered and denied, at our usual and customary office fee. We offer a no-interest or extended (with interest) plan through Care Credit if you need financing. We accept Visa, Mastercard, American Express, and Discover- as well as debit and Apple Pay. Personal checks will be at our discretion and, if the check is returned, a $75 fee will assessed to your account. Accounts 60 days or more past due are subject to a 1.5% fee monthly. In the event legal proceedings are initiated to collect for services rendered, please note you and/or responsible party 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, and Doctor and/or staff time at the rate of $150 per hour. You give South Bay Dental Esthetics permission to contact your employer to verify employment and insurance information.
______ XRAYS: 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-the xrays are digital and your exposure to radiation during them 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:

______ MSDS: 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 initial one or more options below, giving us permission as a way to communicate with you:

We may contact you at your home number
We may contact you on your cellular phone:
We may contact you at your place of business
We may send you an email

We ask that you notify the office of any changes in address, phone, or email, so that we are able to communicate with you effectively. Also let us know if there are any disclosure restrictions or privacy requests you would like us to adhere to, including opting out of text message communication, etc.:

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)