New Patient Form - Town Creek Family Dentistry

Patient Information

Name*

First Last

Nickname

Cell Phone*

Work Phone

Email

Preferred method of contact

Home
Cell/Text
Work
Email

Check all that apply

Birthdate*

Gender

Male
Female

Social Security #

Please upload an image of your face so we’ll recognize you when you come in

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Employer

State ID/Driver's License #

Name of Physician

Physician Phone

In case of Emergency Contact

First Last

Relationship

Emergency Contact Phone

How did you hear about our office?

Medical History

Do you have a history of:

(check all boxes that apply)

Are you currently taking any medications?*

List any medications you are taking:

(including nonprescription drugs)

Are you allergic to any medications?*

Please list them:

Have you ever been told you need to premedicate with antibiotics prior to a dental appointment?*

Date of last medical exam:

Have you been hospitalized?*

What was the problem?

Please include the year, and the reason.
Example: 2008 - Heart Surgery

Do you have any disease or problem you think we should know about?*

Please describe it:

Have you had a transplant operation that has depressed your immune system?*

Do you smoke or chew tobacco?*

How do you use tobacco, and how much?

Have you had Heart Surgery?*

Do you drink alcohol?*

How much do you drink, and how often?

Are you taking or have you ever taken bisphosphonates?*

(Fosamax or Actonel for osteoporosis, chemotherapy, etc.)

Are you taking birth control pills?

Are you pregnant?

Are you nursing/breastfeeding?

Is there a possibility of pregnancy?

NOTE: Antibiotics (such as penicillin) may alter the effect of birth control pills. Consult your physician/gynecologist for assistance regarding additional methods of birth control.

Expected Delivery Date

Dental History Information

Date of last dental visit:

Name of your previous Dentist:

Reason for today's visit:

On a scale from 1 to 10, with 10 being the highest, how important is your dental health to you?

Please enter a number from 1 to 10.

Please Select All That Apply

If you could change something about your smile, what would it be?

Whiter
Straighter
Close gaps between teeth
Replace dark metal fillings with tooth-colored restorations
Repair Chipped Teeth
Replace Missing Teeth
Less Gums Showing

Responsible Party

Is there a Responsible Party for the patient (e.g. parent or guardian)?

Name

First Last

Social Security #

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Preferred Phone

Secondary Phone

Responsible Party Email

Preferred Method of Contact

Email
Text
Phone

Dental Insurance Information

Please upload an image of your dental insurance card

front of card

back of card

Name of Insured

First and Last Name

Relationship to Patient

Self
Spouse
Child
Other

Relationship to Patient*

Self
Spouse
Child
Other

Insured SSN or ID#

Insured SSN or ID#*

Insured Date of Birth

Insured Date of Birth*

Employer

Employer*

Insurance Company

Insurance Company*

Insurance Phone #

Insurance Phone #*

Group Name or #

Group Name or #*

Do you have Secondary Dental Insurance?

Secondary Dental Insurance Information

Relationship to Patient

Self
Spouse
Child
Other

Insured SSN or ID#

Insured Date of Birth

Employer

Insurance Company

Insurance Phone #

Group Name or #

Signature

I certify that I have read and understand the questions above. I acknowledge that the questions have been answered to my satisfaction. I will not hold my Dentist or any other members of his/her staff responsible for any errors that I have made in the completion of this form.

Name*

New Patient Form Completion Signature

Date*

Financial Policy and Agreement

Diagnostic & Consultation Services

All Fees are due at the completion of your diagnostic appointment (today). If you have questions about the amount due today, please ask the receptionist. A treatment plan will be created with estimated costs shown for any future appointments.

Insurance Payments

If you have insurance coverage, we will file the necessary paperwork with your insurance carrier, based on the information you provide for us. We will credit your account with the insurance payment amount when it is received. This is a courtesy offered to our patients, we accept no responsibility or liability due to denied claims, exceeded maximums, or denials due to insurance plan/policy limitations or plan/policy guidelines. You are fully responsible for knowing your own insurance coverage limitations and are liable for any charges incurred because of services rendered regardless of how your insurance pays. You are responsible for knowing what your out of pocket portion will be at the time of treatment. All coverages, co-pays, deductibles and/or amounts due are estimates only.

General Payment Terms

100% of the fee is due at the time of service if the overall treatment cost is $500 or less. If the fee is more than $500 then payment arrangements may be made, please speak to our Financial coordinator for your payment options.
We accept Checks, Cash, and all major credit cards. Payment plans are available through Care Credit or Compassionate Finance upon approval.
Our office does offer 5% discounts for NON-insured Students, Seniors, and those making cash payments at the time of service. A 3% discount is also offered for those paying in full with a credit card. Discounts are not cumulative.Maximum allowable discount is 5%.

Scheduling and Cancellation Policy

Town creek Family Dentistry is dedicated to your quality care and is pleased to reserve your appointment time exclusively for you. We attempt to schedule appointments that are most convenient for you and that fit your personal schedule. We respect our patients time and make every effort to remain on schedule. We understand delays can happen. However, if you know you’ll be more than 10 minutes late, we may have to reschedule. Some visits are more complicated than initially anticipated, and emergencies may arise that could possible delay us. In such a case, every effort will be made to notify you beforehand. Because we reserve time exclusively for each patient, we ask that you make every effort to not change your reserved dental appointment. If you find that you cannot keep your scheduled appointment, we require a minimum 48 hours notification. Last minute cancellations and no shows will be charged a $25 fee that is not covered by insurance and is non refundable. To notify us of any change 48 hours prior, please call our office, leave a voicemail, text or email. If you break two appointments, we will require a 20% deposit to schedule your next appointment. If you break a third appointment you may be dismissed from the practice

Signature

I certify that I have read and understand the above information to the best of my knowledge. I authorize and request my insurance company to pay directly to Town Creek Family Dentistry. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my or my dependents behalf. In the event, that I default on my account(s), I agree to pay collection costs, attorney fees and/or any fees incurred in the attempts of TCFD and its affiliates, to collect this debt or any future debts.

Full Name*

Financial Policy Agreement Signature

Notice of Privacy Practices Acknowledgement

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”), I have certain rights to privacy regarding my protected health information.

I understand that this information can and will be used to:

Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
Obtain payment from third-party payers.
Conduct normal healthcare operations such as quality assessments and physician assessments.

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. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

May we leave a message on your home phone?*

Yes
No

Full Name*

First Last

Signature

Full Name*

Privacy Practices Acknowledgment Signature

Consent For Dental Photography

Full Name*

First Last

At Town Creek Family Dentistry we may take photographs and/or videos of your face, jaws, mouth, and/or teeth before, during, and after treatment. These photographs are used for planning and education and better communication with laboratories and specialists. Photos that depict items of interest, unique findings, or successful outcomes may be of benefit to the dental profession and may be of great value in lectures, seminars, demonstrations, professional publications and/or study clubs. These photos may also be useful for marketing and social media.

I authorize the use of the following types of photos:*

I authorize the use of Full face photos.
I authorize the use of photos only showing lower face, including nose, mouth and teeth.
I do not authorize the use of photos taken of me except for lab communication, consultation with specialists, and team education at TCFD.

I further understand that if the photographs and/or videos are used, I will not be compensated, financial or otherwise, for the use of these photographs.

Signature

Full Name*

Consent for Dental Photography Signature