Irvine Dental New Patient Forms

Welcome

Updated 10/01/2026
Dear New Patient,

It's a privilege for us to be helping you along your healthcare journey with our established practice and team.

Please kindly fill out the following forms so that we may best care for you. If you have any questions, let us know as well. We look forward to seeing you soon.

Sincerely,

Irvine Dental

Patient Information

We are pleased to welcome you to our office. Please take a few minutes to fill out this form as completely as you can. If you have any questions we'll be glad to help you.
PERSONAL
Name

First NameMiddle NameLast Name
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Social Security Number
Gender

Other
Married
Home Phone

Area CodePhone Number
Mobile Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Email
example@example.com
Preferred contact method
Preferred contact method for confirmations
Student status if dependent over 19 (for ins)
How did you hear about us?
If someone referred you here, please write down their name so we can thank them.
ADDRESS AND HOME PHONE
Address same for entire family?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
INSURANCE POLICY
Your relationship to subscriber
Subscriber Name
Subscriber ID #
Subscriber Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Insurance Company
Phone Number

Area CodePhone Number
Employer
Group Name
Group #
Please attach a photo of your insurance card

Browse Files

Cancelof
INSURANCE POLICY 2
Your relationship to subscriber
Subscriber Name
Subscriber ID #
Subscriber Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Insurance Company
Phone Number

Area CodePhone Number
Employer
Group Name
Group #
Please attach a photo of your insurance card

Browse Files

Cancelof
Any additional comments

Patient Treatment and Financial Policy
Patient/Parent name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Dependents

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Thank you for choosing our office as your dental healthcare provider. We are committed to providing you with the highest quality lifetime dental care, so that you may attain optimum oral health.

The following is a statement of our Financial Policy, which we require that you read, agree to and sign prior to any treatment.

Please Note: Payment is due at the time service is provided. Our office accepts cash, personal checks, MasterCard, Visa, Discover, American Express and CareCredit. Outside financing is available upon request and approval.

Please note: Additional fees will be applied for returned checks. All account balances over 90 days are subject to a $35.00 late fee.

Do you have insurance?
- As a courtesy to you, we will help you process all of your dental insurance claims. Please understand that we will provide an insurance estimate to you; however, it is not a guarantee that your insurance will pay exactly as estimated. Insurance coverage is subject to limitations, exclusions, waiting periods, frequency, age restrictions, deductibles and maximums which are your responsibility. Please contact your insurance company for a detail of your benefits. Your insurance company and your plan benefits ultimately determine the amount paid. We will do all we can to ensure your estimate is as accurate as possible. Your estimated insurance benefit may differ due to a number of reasons, specifically related to your plan.
- All charges you incur are your responsibility, regardless of your insurance coverage. We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your insurance company. Your insurance policy is a contract between you and your insurance company. Our office is not a party to that contract.
- Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company's arbitrary determination of usual and customary rates.
- We ask that you sign this form and/or any other necessary documents that may be required by your insurance company. This form instructs your insurance company to make payment directly to our office. I authorize the release of any information concerning my (or my child's) health care advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits.
Print Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature

Payment Arrangement Form
Name of patient:

First NameLast Name
Payment agreement:

I agree that I am responsible for all services rendered to the Patient and that payment is due and payable to the Practice at the time services are rendered and that health, dental and accident insurance policies are an arrangement between my insurance carrier and me. I agree to pay all deductibles and co-pays at the time of service (if I have dual insurance coverage, my co-pay or deductible will be based on the primary coverage). I understand that while the Practice will file claims with my insurance company on my behalf, I remain responsible to the Practice for what is not paid by my insurance company. I also understand that if the Practice cannot verify insurance benefits eligibility for me prior to treatment that I will pay in full for the services at the time they are rendered. I understand that the Practice may charge: 1) a late fee if payment on my account is not received by the due date; 2) an amount equal to $35.00, but not to exceed the maximum amount permitted by law for each returned check, and 3) a fee for each appointment that is missed/canceled without at least 24 hours advance notice. I agree to the extent permitted by law, that if my account balance is referred to any agency or attorney(s) for collection purposes, to pay reasonable attorney's fees and any expenses or costs relating to the collection proceeding, including court costs. I understand that if treatment or care is suspended at any time by the patient, all fees for professional services rendered will be immediately due and payable. I authorize payment directly to the Practice.
RESPONSIBLE PARTY:
Full Name

First NameLast Name
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Employer Name
I acknowledge having received a copy of the Practice's Notice of Privacy Practices. I agree that a photocopy of this authorization is as valid as the original.
Signature of Responsible Party

(to be signed even if Patient is also the Responsible Party)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Acknowledgement of Receipt of Notice of Privacy Practices and Consent Form
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. These rights are more fully described in our Notice of Privacy Practices, updated effective September 23, 2013.

We are permitted to review our Notice of Privacy Practices at any time. We will provide you with a copy of the revised Notice of Privacy Practices upon your request.

Authorization of PHI Disclosure

The information described above may be disclosed to the following recipients:
Name of Person #1

First NameLast Name
Relationship to You
Name of Person #2

First NameLast Name
Relationship to You
I understand that MDSC will not condition treatment, payment, enrollment or eligibility for benefits on whether or not I sign this authorization form, except in the following situations:
- If the medical information to be disclosed will result from treatment for research purposes, MDSC will not provide the treatment if I am unwilling to sign this authorization form.
- If the information to be disclosed will result from treatment provided to me solely for the purpose of creating information to be disclosed to a third party, MDSC will not provide the treatment if I am unwilling to sign this authorization form.
Revocation of PHI Disclosure

I understand that I may revoke this authorization by completing a new Acknowledgement of Receipt of Notice of Privacy Practices and Consent Form. I understand that I may not revoke this authorization during an insurance contestability period or with respect to disclosures that MDSC may have already made in reliance on this authorization. If I revoke this authorization, MDSC will no longer use or disclose my medical information for the reasons covered by this authorization, except to the extent it has already relied upon this authorization. I understand that when MDSC discloses information pursuant to this authorization, the information may no longer be protected by federal or state privacy rules and may be subject to re-disclosure by the recipient of the information.

By signing below, I am acknowledging that I have received a copy of MDSC's Notice of Privacy Practices. I am also giving MDSC consent to disclose my protected health information to the person(s) listed above until such time a new Acknowledgement of Receipt of Notice of Privacy Practices and Consent Form is completed by me. I also understand and agree to the terms of this authorization.
Patient Name

First NameLast Name
Patient Representative

First NameLast Name
If signed by Patient Representative, state authority to act on behalf of patient
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Preferred Pharmacy

Please let us know which pharmacy you would like your prescriptions to be sent to. If you do not see your preferred pharmacy listed, please fill out the address and/or phone number below. Thank you!
Patient Name

First NameLast Name
Select one of the following or fill in information for your pharmacy below:

Other
Pharmacy Phone Number (optional)

Area CodePhone Number
Kaiser MED ID

Patient Communication Consent Form
By opting in, I hereby authorize Irvine Dental to send text message appointment reminders or other health-related communications. I understand that when prompted, I may confirm future appointments using this text messaging service. By accepting these terms, I agree that all individuals associated with my account may receive alerts referencing the account dependents. Text message charges from my cell phone provider may apply.

I may opt-out of receiving these communications at any time by calling the office at 949-559-1814, or by replying STOP to 949-771-1943.

I understand that text messaging is not a secure format of communication. There is some risk that individually identifiable health information or other sensitive or confidential information contained in such text may be misdirected, disclosed to, or intercepted by unauthorized third parties. Information included in text messages may include your first name, date/time of appointments, or other pertinent information. I understand that text messages are not a substitute for professional or medical attention.
Text Message Communications
My text/mobile number is:

Area CodePhone Number
I prefer to not participate in electronic communication via text messaging. Please call me at this number regarding appointment confirmations, information about treatment, payment or regarding my account instead: .
Signature

My signature indicates that I agree to all the terms and conditions of use for the services I have opted in for and the information that has been provided. I understand that I can opt out at any time.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Appointment/Cancellation/No Show Policy

Irvine Dental Effective 01/01/2018
Appointments

Office visits are by appointment only please call (949-559-1814). The receptionist may ask about the reason for your visit. This helps us schedule the time more efficiently. Please arrive 10 minutes early for your appointment. Patients who are late for any appointment may be asked to reschedule at the dentist/hygienist's discretion.

Cancellations

We would like to thank you for being a patient in our office. We value all of our patients and strive to provide the best dental care possible in the most comfortable setting. Please understand that when we schedule your appointment, we are reserving time for your particular needs. We kindly ask that if you must change an appointment, please give us at least 24 hours' notice. This courtesy makes it possible to give your reserved time to another patient who would like it. We know that your time is valuable. When your appointment is made, a room is reserved, your records are prepared, and special instruments are readied for your visit. Except in the case of emergency treatment for another patient, you can expect us to be running on schedule. If you are unable to keep an appointment, we ask that you cancel at least 24 hours in advance. If this is not possible, call as soon as you can so that another patient can be given your appointment time.

Missed Appointments (Non-Cancelled)

We understand that occasional missed appointments can occur for a variety of reasons. When you miss an appointment without canceling, someone else who could have been seen in your place is delayed unnecessarily. We track missed (non-cancelled) appointments. A "No Show/Late Cancellation" is defined as missing an appointment without cancelling at least 24 hours before scheduled time. There will be a charge for a missed or non-cancelled appointment. Insurance will not cover charges for no show/late or late cancellation fees. The $50 charge is in addition to any other charges you may have incurred. No refunds will be given. Repeated missed appointments may result in discharging you from the practice. We will offer 30 days of emergent care only and transfer your dental records when you find a new dentist. Payments are due in full at the time of service no exceptions.
Patient Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Should be Empty:

Rows	YES	NO
Latex
Epinephrine
Local anesthetics
Aspirin
Penicillin
Amoxicillin
Motrin (Ibuprofen)
Other

Rows	YES	NO
Aredia (bisphosphonates)
Alendronate (Fosamax)
Risedronate (Actonel) for osteoporosis or Paget's
Redux (dexphenfluramine)
Pondimin (fenfluramine)
Zometa
Phen-fen

Rows	YES	NO
Artificial heart valves
Artificial joint/hip/knee
Diabetes
Pacemaker
Heart murmur
Heart attack
High blood pressure
Low blood pressure
Mitral valve prolapse
Rheumatic fever
Thyroid problem
AIDS/HIV
Pregnancy
Kidney disease
Liver disease/Hepatitis
Cancer
Arthritis
Sinus trouble
Psychiatric treatment
Bleeding problem
Autoimmune disease
Lupus
Acid reflux
Cold sores
Epilepsy
Fainting or seizures

Welcome

Patient Information

Medical History for New Patient

Patient Treatment and Financial Policy

Payment Arrangement Form

Acknowledgement of Receipt of Notice of Privacy Practices and Consent Form

Preferred Pharmacy

Patient Communication Consent Form

Appointment/Cancellation/No Show Policy