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(865) 816-6327
TEAM
SERVICES
CONTACT
TESTIMONIALS
NEW PATIENTS
MEMBERSHIP
(865) 816-6327
TEAM
SERVICES
CONTACT
TESTIMONIALS
NEW PATIENTS
MEMBERSHIP
Search for:
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
*
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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:
A.I.D.S./HIV Positive
Alcoholism
Allergies
Anemia
Arthritis
Asthma
Blood Disease
Bone Disease
Cancer
Chemical Dependency
Chest Pain
Circulatory Problems
Convulsions/Seizures
Diabetes
Excessive Bleeding
Epilepsy
Glaucoma
Hay Fever
Head Injuries
Hearing Impaired
Heart Disease
Heart Valve, Murmur
Hepatitis/Liver Disease
Hepatitis Carrier
High Blood Pressure
Hip or Joint Replacement
HPV
Jaundice
Kidney Disease
Kidney Dialysis
Latex Sensitivity
Lupus
Low Blood Pressure
Malignancies
Mitral Valve Prolapse
Neck & Back Problems
Nervous Problems/Disorders
Pacemaker
Prosthetic Joints
Psychiatric Care
Radiation Treatment
Respiratory Problems/Disorders
Rheumatic Fever
Rheumatism
Scarlet Fever
Seizures/Fainting Spells
Sinus Problems
Stomach Ulcers
Stroke
Thyroid Disease
Tuberculosis
Tumers or Growths
Ulcers
Venereal Disease
(check all boxes that apply)
Are you currently taking any medications?
*
Select
Yes
No
List any medications you are taking:
(including nonprescription drugs)
Are you allergic to any medications?
*
Select
Yes
No
Please list them:
Have you ever been told you need to premedicate with antibiotics prior to a dental appointment?
*
Select
Yes
No
Date of last medical exam:
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Have you been hospitalized?
*
Select
Yes
No
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?
*
Select
Yes
No
Please describe it:
Have you had a transplant operation that has depressed your immune system?
*
Select
Yes
No
Do you smoke or chew tobacco?
*
Select
Yes
No
How do you use tobacco, and how much?
Have you had Heart Surgery?
*
Select
Yes
No
Do you drink alcohol?
*
Select
Yes
No
How much do you drink, and how often?
Are you taking or have you ever taken bisphosphonates?
*
Select
Yes
No
(Fosamax or Actonel for osteoporosis, chemotherapy, etc.)
Are you taking birth control pills?
Select
Yes
No
Are you pregnant?
Select
Yes
No
Are you nursing/breastfeeding?
Select
Yes
No
Is there a possibility of pregnancy?
Select
Yes
No
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
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Dental History Information
Date of last dental visit:
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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
I have had an oral cancer screening
I floss often
My gums bleed when I brush
I have had a complication from an extraction
My jaw pops or clicks when I chew
I am prone to frequent headaches
I grind or clench my teeth
I have sores, blisters, or swelling on my gums, lips, or cheeks
I have had orthodontic treatment
I snore
I have problems with bad breath
I have had an allergic reaction to a crown, metal filling, or dental appliance
I use an electric toothbrush
My teeth are sensitive to hot, cold, or pressure
I have had a sleep study
I have sleep apnea
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)?
Select
Yes
No
Name
First
Last
Social Security #
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
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Bermuda
Bhutan
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Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
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Bouvet Island
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British Indian Ocean Territory
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Canada
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Chile
China
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Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
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Curaçao
Cyprus
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Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
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Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
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Greenland
Grenada
Guadeloupe
Guam
Guatemala
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Guinea
Guinea-Bissau
Guyana
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Heard and McDonald Islands
Holy See
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Hungary
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India
Indonesia
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Iraq
Ireland
Isle of Man
Israel
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Japan
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Lao People's Democratic Republic
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Libya
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Mali
Malta
Marshall Islands
Martinique
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Mayotte
Mexico
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Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
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Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
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Panama
Papua New Guinea
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Poland
Portugal
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Qatar
Romania
Russia
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Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
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
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Insured Date of Birth
*
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Employer
Employer
*
Insurance Company
Insurance Company
*
Insurance Phone #
Insurance Phone #
*
Group Name or #
Group Name or #
*
Do you have Secondary Dental Insurance?
Select
Yes
No
Secondary Dental Insurance Information
Relationship to Patient
Self
Spouse
Child
Other
Insured SSN or ID#
Insured Date of Birth
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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
*
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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