• Patient Information

  • Current Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender*
  • Do you have an email?*

  • Responsible Party*
  • Does the patient has any siblings (under 18 years) accompanying for the same appointment?
  • Do you have any kids (under 18 years old) accompanying you for the same appointment?
  • Are you a new patient?*

  • Responsible Party's Information

  • Relation to the patient*

  • Existing Patient

  • If there is change in any of the following, please check the box*

  • Phone Number

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Emergency Contact

  • Format: (000) 000-0000.

  • Insurance

  • Please Specify

  • Primary Insurance

  • Secondary Insurance

  • Patient Consent For Electronic Insurance Claim Submission

    Please review the following if you would like our office to process your dental insurance claims electronically.

  • I AUTHORIZE the release, to my dental benefits plan administer and the CDA, information contained in claims submitted electronically. I also AUTHORIZE the communication of information related to the coverage of services described to Dr. Rajan Verma or Pro Dental Concepts. This AUTHORIZATION shall continue in effect until the undersigned revokes the same.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • New Patient

  • Telephone

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Emergency Contact

  • Format: (000) 000-0000.

  • Referring Dentist / Clinician

  • Insurance Policy Information

    Please provide us with your Insurance Benefits Card
  • Do you have insurance?*
  • Please specify*

  • Primary Insurance

  • Secondary Insurance

  • Patient Consent For Electronic Insurance Claim Submission

    Please review the following if you would like our office to process your dental insurance claims electronically.

  • I AUTHORIZE the release, to my dental benefits plan administer and the CDA, information contained in claims submitted electronically. I also AUTHORIZE the communication of information related to the coverage of services described to Dr. Rajan Verma and/or Pro Dental Concepts. This AUTHORIZATION shall continue in effect until the undersigned revokes the same.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Medical Health History

  • Gender
  • In the last 3 years, have you been hospitalized, had serious illness or had surgery?*

  • If you have a printed medication list, please provide it to the front staff. Thank you.

  • Do you have any Allergies or Adverse Reactions? (Medications, Latex, Food, Other)*
  • Do you have/had or ever experienced any of the following Medical Diseases? Please check mark the responses.
    Rows
  • Have you had any of the following? Please Circle and indicate the date of treatment.*
    Rows
  • Do you carry or have ever used "Nitro"?*
  • Did you have Prosthetic Joint Replacement?*
  • Has your surgeon recommended prophylactic antibiotic prior to dental treatments?
  • Do you have Diabetes Type 1 or Diabetes 2 ?*
  • Do you take Blood Thinners?*
  • Do you have High Blood Pressure?*
  • Do you have a history of Cancer?*
  • Do you have a history of Leukemia?
  • Do you have a history of Malignant Tumours?*
  • Did you have Bisphosphonates / Anti-Resorptives?*
  • How were they administered?
  • Do you have Sleep Apnea?
  • Do you wear a C-PAP?
  • Are you currently smoking?*
  • Do you have E-Cigarettes?
  • Do you chew tobacco?*
  • Have you formerly smoked?*
  • Do you have a plan / date to quit smoking?
  • Do you take recreational drugs?
  • Do you consume alcohol?
  • Are you pregnant?*
  • What is the due date?
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you presently

  • Dental History

  • Do you have a previous general Dentist?*

  • Information Release

  • To

     {generalDentists}

    {dentalPractice}

    {dentalPractice594} 

    I authorize the above Dentist to release my dental records, including x-rays and the last record of the requested treatment to:

     

    Pro Dental Concepts

    Dr. Rajan Verma

    2020 E Main Street

    St. Charles, IL

    60174

    Phone Number: 630-513-7884

     

    Please send digital x-rays to: infoprodentalconcepts@gmail.com
    I release you from all legal responsibility or liability that may arise from this authorization.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Which oral hygiene aids do you currently use:
  • Please check all that apply to your current Dental situation:
  • Please check mark the given symptoms
    Rows
  • Did you have the following treatments
    Rows
  • Do you own / wear an occlusal appliance (night guard) ?
  • Do you have any missing teeth?
  • Are you interested in Implants to replace the missing teeth?
  • Did you have any prior vehicle accident or trauma to head, neck, jaw(s) and/or teeth?
  • Do you have or had any serious dental problems, diseases or conditions that are not listed above?

  • Family Member

    • Family Member 1 
    • Gender*
    • Is your child a new patient?*
    • Does your child have any previous general dentist?*

    • Medical History

    • Information Release

    • To {previousGeneral}

      I authorize the above Dentist to furnish my child's ({name272}) dental records, including x-rays and the last record of the requested treatment to:

       

      Pro Dental Concepts

      Dr. Rajan Verma

      2020 E Main Street

      St. Charles, IL

      60174

      Phone Number: 630-513-7884

       

      Please send digital x-rays to: infoprodentalconcepts@gmail.com
      I release you from all legal responsibility or liability that may arise from this authorization.

    •
    • Which oral hygiene aids does your child currently use:
    • Please check all that apply to your child's current Dental situation:
    • Please check mark the given symptoms
      Rows
    • Did your child have the following treatments
      Rows
    • Please Answer the following
      Rows
    • Does your child have or had any serious dental problems, diseases or conditions that are not listed above?
    • Family Member 2 
    • Gender*
    • Is your child a new patient?*
    • Does your child have any previous general dentist?*

    • Information Release

    • To {previousGeneral360}

      I authorize the above Dentist to furnish my child's ({name276}) dental records, including x-rays and the last record of the requested treatment to:

       

      Pro Dental Concepts

      Dr. Rajan Verma

      2020 E Main Street

      St. Charles, IL

      60174

      Phone Number: 630-513-7884

       

      Please send digital x-rays to: infoprodentalconcepts@gmail.com
      I release you from all legal responsibility or liability that may arise from this authorization.

    •
    • Which oral hygiene aids does your child currently use:
    • Please check all that apply to your child's current Dental situation:
    • Please check mark the given symptoms
      Rows
    • Did your child have the following treatments
      Rows
    • Please Answer the following
      Rows
    • Does your child have or had any serious dental problems, diseases or conditions that are not listed above?
    • Family Member 3 
    • Gender*
    • Is your child a new patient?*
    • Does your child have any previous general dentist?*

    • Information Release

    • To {previousGeneral361}

      I authorize the above Dentist to furnish my child's ( {name316}) dental records, including x-rays and the last record of the requested treatment to:

      Pro Dental Concepts

      Dr. Rajan Verma

      2020 E Main Street

      St. Charles, IL

      60174

      Phone Number: 630-513-7884

       

      Please send digital x-rays to: infoprodentalconcepts@gmail.com
      I release you from all legal responsibility or liability that may arise from this authorization.

    •
    • Which oral hygiene aids does your child currently use:
    • Please check all that apply to your child's current Dental situation:
    • Please check mark the given symptoms
      Rows
    • Did your child have the following treatments
      Rows
    • Please Answer the following
      Rows
    • Does your child have or had any serious dental problems, diseases or conditions that are not listed above?
    • Family Member 4 
    • Gender*
    • Is your child a new patient?*
    • Does your child have any previous general dentist?*

    • Information Release

    • To {previousGeneral362}

      I authorize the above Dentist to furnish my child's ( {name317} ) dental records, including x-rays and the last record of the requested treatment to:

      Pro Dental Concepts

      Dr. Rajan Verma

      2020 E Main Street

      St. Charles, IL

      60174

      Phone Number: 630-513-7884

       

      Please send digital x-rays to: infoprodentalconcepts@gmail.com
      I release you from all legal responsibility or liability that may arise from this authorization.

    •
    • Which oral hygiene aids does your child currently use:
    • Please check all that apply to your child's current Dental situation:
    • Please check mark the given symptoms
      Rows
    • Did your child have the following treatments
      Rows
    • Please Answer the following
      Rows
    • Does your child have or had any serious dental problems, diseases or conditions that are not listed above?
    • Family Member 5 
    • Gender*
    • Is your child a new patient?*
    • Does your child have any previous general dentist?*

    • Information Release

    • To {previousGeneral363}

      I authorize the above Dentist to furnish my child's ( {name318} ) dental records, including x-rays and the last record of the requested treatment to:

      Pro Dental Concepts

      Dr. Rajan Verma

      2020 E Main Street

      St. Charles, IL

      60174

      Phone Number: 630-513-7884

       

      Please send digital x-rays to: infoprodentalconcepts@gmail.com
      I release you from all legal responsibility or liability that may arise from this authorization.

    •
    • Which oral hygiene aids does your child currently use:
    • Please check all that apply to your child's current Dental situation:
    • Please check mark the given symptoms
      Rows
    • Did your child have the following treatments
      Rows
    • Please Answer the following
      Rows
    • Does your child have or had any serious dental problems, diseases or conditions that are not listed above?
    • Family Member 6 
    • Gender*
    • Is your child a new patient?*
    • Does your child have any previous general dentist?*

    • Information Release

    • To {previousGeneral364}

      I authorize the above Dentist to furnish my child's ( {name319} )  dental records, including x-rays and the last record of the requested treatment to:

      Pro Dental Concepts

      Dr. Rajan Verma

      2020 E Main Street

      St. Charles, IL

      60174

      Phone Number: 630-513-7884

       

      Please send digital x-rays to: infoprodentalconcepts@gmail.com
      I release you from all legal responsibility or liability that may arise from this authorization.

    •
    • Which oral hygiene aids does your child currently use:
    • Please check all that apply to your child's current Dental situation:
    • Please check mark the given symptoms
      Rows
    • Did your child have the following treatments
      Rows
    • Please Answer the following
      Rows
    • Does your child have or had any serious dental problems, diseases or conditions that are not listed above?
    • Family Member 7 
    • Gender*
    • Is your child a new patient?*
    • Does your child have any previous general dentist?*

    • Information Release

    • To {previousGeneral364}

      I authorize the above Dentist to furnish my child's ( {name319} )  dental records, including x-rays and the last record of the requested treatment to:

      Pro Dental Concepts

      Dr. Rajan Verma

      2020 E Main Street

      St. Charles, IL

      60174

      Phone Number: 630-513-7884

       

      Please send digital x-rays to: infoprodentalconcepts@gmail.com
      I release you from all legal responsibility or liability that may arise from this authorization.

    •
    • Which oral hygiene aids does your child currently use:
    • Please check all that apply to your child's current Dental situation:
    • Please check mark the given symptoms
      Rows
    • Did your child have the following treatments
      Rows
    • Please Answer the following
      Rows
    • Does your child have or had any serious dental problems, diseases or conditions that are not listed above?
    • Family Member 8 
    • Gender*
    • Is your child a new patient?*
    • Does your child have any previous general dentist?*

    • Information Release

    • To {previousGeneral364}

      I authorize the above Dentist to furnish my child's ( {name319} )  dental records, including x-rays and the last record of the requested treatment to:

      Pro Dental Concepts

      Dr. Rajan Verma

      2020 E Main Street

      St. Charles, IL

      60174

      Phone Number: 630-513-7884

       

      Please send digital x-rays to: infoprodentalconcepts@gmail.com
      I release you from all legal responsibility or liability that may arise from this authorization.

    •
    • Which oral hygiene aids does your child currently use:
    • Please check all that apply to your child's current Dental situation:
    • Please check mark the given symptoms
      Rows
    • Did your child have the following treatments
      Rows
    • Please Answer the following
      Rows
    • Does your child have or had any serious dental problems, diseases or conditions that are not listed above?

  • HIPAA Privacy Consent Form

  • PATIENT CONSENT FORM: FOR COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION

  • Consent for Consultation and Financial Agreement

  • How Our Office Collects, Uses and Discloses Patients’ Personal Information

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: