Crown Pointe Dentistry Patient Intake

Patient Type

Slot ID

Visit Type

Appointment Time

Appointment Date

Provider

Name

First NameLast Name

Email

example@example.com

Phone Number

Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth

Date

Full Face Photo

Dou you have dental insurance?

Is the patient the policy primary?

Choose how you would like to share your insurance policy information.

Name of Insured

Relationship to Patient

Date of Birth

Insurance Provider

Employer

Group Number

Member ID

Please upload a photo of your insurance card.

Who is your previous dentist?

Previous Dentist's Name

City & State

Phone Number

How long has it been since you've seen a dentist?

How long has it been since you've seen a dentist?

When was your last complete dental exam?

When was your last complete set of dental x-rays?

Are you having problems now?

Please describe your dental concerns in detail.

Do you wear dentures?

Are you unhappy with your dentures?

Have you had periodontal (gum) treatments?

Do your gums bleed, or feel tender or irritated?

Are your teeth sensitive to hot, cold, sweets, or pressure?

Are you unhappy with the appearance of your teeth?

Please explain.

Are you aware of grinding or clenching your teeth?

Do you have headaches, earaches, or neck pain?

Do you wear a night guard?

Do you use an electric toothbrush?

Do you have loose, chipped, or shifting teeth?

Have you worn braces on your teeth?

Do you have discolored teeth that bother you?

Would you like your smile to look better or different?

Are you interested in whitening your teeth?

Do you have problems with fillings or teeth breaking?

Do you regularly use dental floss?

Do you experiment with recreational drugs?

Are you aware of being allergic to, or adversely reacting to any medications?

How would you rank your goals for dental care? Using your finger or mouse, click to drag rearrange the list from highest priority to lowest priority.

Please list known allergies or adverse reactions.

How did you hear about our office?

Do you have any current health problems?

Please summarize your health problems.

Are you under a physician's care?

Phyisican's name

Physician's phone number

Are you currently taking medications?

Please list all medication, prescription and OTC.

Are you pregnant?

Do you smoke?

Do you use smokeless tobacco?

Approximate height in inches.

Approximate weight in pounds.

Medical History

Bone density medications often include drugs from a class called "bisphosphonates". These may include such brand names as Actonel, Fosamax, Boniva, Reclast, Aredia, and Didronel. Please indicate below if you are on any of these drugs, or any other bisphosphonate medication.

Blood thinner medications are often prescribed by your doctor to protect against heart attacks and strokes. Some brand name examples include: Eliquis, Pradaxa, Fragmin, Savaysa, Lovenox, Arixtra, Innohep, Xarelto, Coumadin, Jantoven, Aspirin, Plavix, Persantine, Integrilin, Effient, Brilinta, Aggrastat, Zontivity. Please list any known blood thinner medications that you are currently taking.

To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail.

Acknowledgement of Medical and Dental History

Welcome to our practice,

From the moment you walk through our door you will notice that our goal is to make you feel at home in our pleasant, relaxed atmosphere. Our friendly staff will take special care to make certain that you are comfortable and well cared for.

We provide advanced dental care, and have dedicated our practice to excellence in painless dentistry. Your dental health is of the utmost importance to us. We will educate and counsel you on all procedures that you may require. Our staff is prepared to help train our patients in preventive dental care and proper hygiene.

We look forward to a long term professional relationship with people such as you; to this end we have prepared the following so that you know what is expected of you, and we welcome you to our practice.

Payment Responsibilities:

Payment is due at the time services are rendered, unless payment arrangements have been approved in advance. For your convenience we accept MasterCard, Visa, Discover, American Express & Care Credit. Returned checks and balances older than 30 days will be subject to additional collection fees and interest charges. Charges may also be assessed for repeated missed appointments without a 24 hour advanced notice.

Insurance Policy:

We will file with your insurance company, but all patient portions are due at the time of service. Patient portions are calculated based on information we receive from your insurance company.

However, your insurance is a contract between you, your employer, and the insurance company. We are not a party to that contract. Our fees are generally considered within the acceptable range by most companies and therefore are covered up to the maximum allowance determined by each carrier. Not all services, however, are a covered benefit in all contracts.

We must emphasize that as dental care providers our relationship is with you-not your insurance company. All charges are you responsibility from the date the services are rendered.

I have read and understood the above financial policy.

Acknowledgement of Financial Policies

The Health Insurance Portability & Accountability Act of 1996 (HIPAA). I understand that this information can and will be used to:

Provide & coordinate my treatment among a number of health care providers who may be involved in that treatment directly and indirectly.

Obtain payment from third-party payers for my health services. Conduct normal health care operations such as quality assessment and improvement activities.

I have been informed of my dental provider’s Notice of Privacy Practices contain a more complete description of the uses and disclosures of my protected health information. I have been given the right to review and receive a copy of such Notice of Privacy Practices. I understand that my dental provider has the right to change the Notice of Privacy Practices and that I may contact this office at the address above to obtain a current copy of the Notice of Privacy Practices.

At times we will need to contact you concerning information that is specific to you, your treatment and your dental needs. Information that is requested to be sent to you, or on your behalf, by our office via email will be sent in standard email format. We do not have encrypted services available for such communication. We may have the need to use the telephone for confirmation of appointments or verification of health/dental needs. We will remain mindful all HIPAA laws concerning release of information in these instances.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations and I understand that you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

Acknowledgement of Privacy Practices

We recommend that patients who are new to our practice schedule for a comprehensive examination, which includes a 60 minute examination with a dental hygienist and a 60 minute examination with the dentist.

The comprehensive exam will require a full set of x-rays, a periodontal chart to evaluate gum health, and photos of your teeth and gums for education and treatment planning. Depending on the condition of your periodontal health, we may or may not be able to complete a teeth cleaning during the visit.

If you have a problem focused need such as toothache or a second opinion, you may ask to be scheduled or a limited examination with the doctor. You will not have your teeth cleaned at this visit and we will only take x-rays necessary to diagnose your problem. You may be re-scheduled at a later time for a comprehensive examination.

Please choose your visit type.

Please use your finger or mouse to click and drag the days of the week into your preferred scheduling order.

Availability Preference

Please provide any additional information that you would like for your doctor to know prior to your visit.

Additional information

Demographic Information

Insurance Information

Dental History

Medical History

Financial Policies

Acknowledgement of Privacy Practice - HIPAA

Appointment Request