New Patient FormWeaver Dentistry | 616-942-4010 Please take a moment to enter your information to help us ensure the quality of your care is excellent. Patient Information Patient Name * First Name Last Name Preferred Name Title Mr/Ms/Mrs/ect Gender * Male Female Family Status * Married Single Child Other Birth Date * Social Security Number * Email Address * Phone * (###) ### #### Best Time to Call Emergency Contact * Name, Phone Number and Relationship Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Drivers License Number * Preferred Method of Contact * Phone Email Name of person, office, or other source referring you to our practice * Spouse or Responsible Party Information The following is for: * The Patient's Spouse The Person Responsible for Payment Both Neither/Not Applicable Name * First Name Last Name Preferred Name Title Gender * Male Female Family Status * Married Single Child Other Birth Date * Email Address * Phone * (###) ### #### Best Time to Call Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Employment Information The following is for: * The Patient The Person Responsible for Payment Both Not Applicable Employer Name * First Name Last Name Employer Phone * (###) ### #### Employer Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Primary Insurance Information Name of Insured * First Name Last Name Insured's Birth Date * Plan ID Number * Plan Group Number * Insured's Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Insured's Employer Name * Employer Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Patient's Relationship to Insured * Self Spouse Child Other Insurance Plan Name * Insurance Address * Address 1 Address 2 City State/Province Zip/Postal Code Country By Checking these Sections: * I authorize my insurance to pay my benefits directly to Weaver Dentistry for all services rendered when applicable. I authorize the use of this electronic signature on all insurance submissions. I authorize Weaver Dentistry to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges, whether or not paid by insurance. Secondary Insurance Information Name of Insured First Name Last Name Insured's Birth Date Plan ID Number Group ID Number Insured's Address Address 1 Address 2 City State/Province Zip/Postal Code Country Insured's Employer Name Employer Address Address 1 Address 2 City State/Province Zip/Postal Code Country Patients Relationship to Insured Self Spouse Child Other Insurance Plan Name Insurance Address Address 1 Address 2 City State/Province Zip/Postal Code Country By Checking these Sections: I authorize my insurance to pay my benefits directly to Weaver Dentistry for all services rendered when applicable. I authorize the use of this electronic signature on all insurance submissions. I authorize Weaver Dentistry to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges, whether or not paid by insurance. Dental History What is the reason for your visit today? * Approximate date of your last dental visit for a professional cleaning? * MM DD YYYY Previous dentist's name, address and phone. * How often do you get your teeth cleaned? * Once a year Every 4-6 months Every 1-3 months How often do you brush your teeth? * Once a day Twice a day More than once a day How often do you floss? * Never Once a day Twice a day After every meal What other dental aides do you use? * Electric toothbrush, toothpicks, etc Do you have any dental problems now? * Yes No If yes, please describe: Are your teeth sensitive to any of the following? Hot Cold Sweets Metals Biting Chewing Have you noticed any mouth odors or bad taste? * Yes No If yes, please describe: Do you frequently get cold sores, blisters or any other lesions? * Yes No Do your gums bleed or hurt? * Yes No Have your parents experienced gum disease? * Yes No Have your parents experienced tooth loss? * Yes No Have you noticed any loose teeth or changes to your bite? * Yes No Do you: Clench or grind your teeth while awake or asleep? Bite your cheek or lips regularly? Hold foreign objects with your teeth? (pencils, pipes, pens, nails, etc) Mouth breathe while awake or asleep? Have tired jawas, especially in the morning? Snore or have any other sleeping disorder? Wear a snore guard? Use a C-pap appliance? Have you ever had: Orthodontic Treatment Oral Surgery Periodontal Treatment Bite Plate or Mouth Guard Have you ever had a serious injury to the mouth or head? * Yes No If yes, please describe: Have you experienced: Popping or clicking in the jaw? Pain (jaw, ear, side of face) Headaches, neck aches, shoulder aches? Are you satisfied with your teeth's appearance? * Yes No Would you like to keep all your teeth all your life? * Yes No Do you feel nervous about having dental work done? * Yes No If yes, please describe: Have you ever had an upsetting dental experience? * Yes No If yes, please describe: Is there anything else about your dental care you think we should know about? * Yes No If yes, please describe: Health History So that we provide you with the best possible care please complete all parts of this form. All information is completely confidential. How would you describe your overall health? * Choose one Excellent Good Average Fair Poor Physician's Name, Address, & Phone Number * When was your last physical? * Choose one Within 1 year 2-5 years Over 5 years Have you been hospitalized under a physician's care in the last two years? * Yes No If so, why? * Please indicate if you have any medical conditions * Please list all allergies or reactions to medications or substances * Please list any medications you are currently taking * Have you taken any bone density medications? * Yes No Have you been told you need to pre-medicate for dental visits? * Yes No If yes, for what reason? Please check any tobacco use or other recreational habits Smoke Cigarettes Chew Tobacco Marijuana Use Vape Alcohol Use Women: Do you use birth control medications? Yes No Does not apply Women: Are you pregnant or think you may be pregnant? Yes No Does not apply Women: Are you nursing? Yes No Does not apply Consent for Treatment * 1. I hereby authorize doctor or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by doctor to make a through diagnosis of the patients dental needs. 2. Upon such diagnosis, I authorize doctor to preform all recommended treatment, mutually agreed upon by me and to employ such assistance as required to provide proper care. 3. I agree to the use of anesthetics, sedatives, and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications. 4. I give consent to the doctors or designated staffs use and disclosure of any oral, written or electronic health records that are individually identifiable as mine for quality care will be used or disclosed and that a notice fully outlining the protection of my personal health information is available. 5. I agree to be responsible for payment and all service rendered on my behalf or my dependents. I understand that payment is due at the time of service unless other arrangements have been made. In the event payments are not received by agreed upon dates, I understand that at 1.5% late charge (18% APR) may be added to my account. If required, I also understand a check of my credit history may be made. I have read the above conditions of treatment and payment and agree to their contract. Notice of Privacy Practices Acknowledgement The privacy of your health information is important to us. Our Notice of Privacy Practices describes how your health information will be handled in various situations. We ask that you sign this form to acknowledge that you received a copy of our Notice of Privacy Practices. By checking this box, I acknowledge that I have received a copy of the dental practice's Notice of Privacy Practices. Response Date * MM DD YYYY By checking this box, I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective healthcare provider or agency who may release such information to you. I will notify the dentist of any changes in my health or medications. * Option 1 Option 2 Relationship to Patient: * Thank you!
