New Patient Form

dinka dental

New Patient Information Form

Please complete the online form below prior to your first appointment at Dinka Dental. To download and print this form, click here.

Step 1 of 7 - Patient Info

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Appointment Information

Date of Scheduled Appointment(Required)

MM slash DD slash YYYY

Patient's Contact Information

Patient's Name(Required)

Patient's Birthday(Required)

Patient's Phone(Required)

Patient's Address(Required)

Patient's Email Address(Required)

Patient's Basic Information

Patients SS#(Required)

# of Dependents

Whom May We Thank for Referring You?

Emergency Contact:

What is the patient's gender?

Female

Male

What is the patient's marital status?

Divorced

Married

Single

Separated

Widowed

Is the patient currently employed?

Employed - Yes

Yes

Employed - No

Does the patient have dental insurance?

Insurance - Yes

Yes

Insurance - No

Spouse's Information

Spouse's Full Name

Spouse's Employer

Spouse's Social Security #

Patient's Employer Information

Employer's Name

Employer's Phone

# of Yrs Employed

Employer's Address

Payment Information

Who is the financially responsible party for this account? (This will be the name listed on your billing statements)

Who Will Pay - Self

Self / I am

Who Will Pay - Parent or Guardian

Parent or Guardian

Who Will Pay - Spouse

My Spouse

Financially Responsible Party's Information

Responsible Party's Full Name

Responsible Party's Birthdate

Responsible Party's SS#

Phone

Address

Responsible Party's Employer

# of Years with Employer

Work Phone #

Employer's Address

What is the responsible party's gender?

Responsible Party - Female

Female

Responsible Party - Male

Male

Dental Insurance Information

Subscriber's Full Name

Subscriber's Birthdate

Subscriber's SS#

Subscriber's Employer

Employer's Address

Name of Insurance Provider

Group Number

Max Benefit Amount

Benefit Year

Is there a deductible?

Deductible Yes

Yes

Deductible No

What is the patient's relationship to the subscriber?

Relationship to Subscriber - Self

Self

Relationship to Subscriber - Spouse

Spouse

Relationship to Subscriber - Dependent

Dependent

Have you used your dental insurance previously?

Used Dental Insurance Previously - Yes

Yes

Used Dental Insurance Previously - No

Have you have additional / secondary dental insurance coverage?

More Than 1 Dental Plan - Yes

Yes

More Than 1 Dental Plan - No

Additional / Secondary Dental Insurance Information

Subscriber's Full Name

Relationship to Patient

Subscriber's Birthday

Subscriber's SS#

Subscriber's Employer

Name of Insurace Provider

Group Number

Patient's Health Information & History

Physician's Name

Date of Last Physical

Physician's Address

How is your/the patient's general health?

General Health - Excellent

Excellent

General Health - Good

Good

General Health - Fair

Fair

General Health - Poor

Poor

Currently taking prescription medication?

Taking Meds - Yes

Yes

Taking Meds - No

Brief Purpose for Medication

Treated for heart disease?

Heart Disease - Yes

Yes

Heart Disease - No

Diagnosed with a heart murmur?

Heart Murmur - Yes

Yes

Heart Murmur - No

Diagnosed with rheumatic fever?

Rheumatic Fever - Yes

Yes

Rheumatic Fever - No

Diagnosed with jaundice?

Jaundice - Yes

Yes

Jaundice - No

Diagnosed with abnormal blood pressure?

Abn Blood Pressure - Yes

Yes

Abn Blood Pressure - No

Diagnosed with asthma?

Asthma - Yes

Yes

Asthma - No

Diagnosed with ulcers?

Ulcers - Yes

Yes

Ulcers - No

Have sinus issues?

Sinus Trouble - Yes

Yes

Sinus Trouble - No

Diagnosed with tuberculosis?

Tuberculosis - Yes

Yes

Tuberculosis - No

Treatment for cough?

Cough - Yes

Yes

Cough - No

Diagnosed with diabetes?

Diabetes - Yes

Yes

Diabetes - No

Diagnosed with epilepsy?

Hep -Yes

Yes

Hep - No

Diagnosed with hepatitis?

Epilepsy - Yes

Yes

Epilepsy - No

Diagnosed with arthritis?

Arthritis - Yes

Yes

Arthritis - No

Diagnosed with anemia?

Anemia - Yes

Yes

Anemia - No

Diagnosed with a stroke?

Stroke - Yes

Yes

Stroke - No

Diagnosed with heart lesions?

Heart Lesions - Yes

Yes

Heart Lesions - No

Diagnosed with glaucoma?

Glaucoma - Yes

Yes

Glaucoma - No

Diagnosed with a venereal disease?

VD - Yes

Yes

VD - No

Been involved in a serious accident?

Serious Accident - Yes

Yes

Serious Accident - No

Diagnosed with HIV/AIDS?

Aids - Yes

Yes

Aids - No

Treated (other than diagnostic) with x-ray?

Treated w X Ray - Yes

Yes

Treated w X Ray - No

Allergic to any of the following? (check all that apply)

Allergic - Codeine

Codeine

Allergic - Penicillin

Penicillin

Allergic -Local Anesthesia

Local Anesthesia

Allergic - Other Meds

Other Meds

Allergic to:(Required)

Ever had prolonged bleeding?

Prolonged Bleeding - Yes

Yes

Prolonged Bleeding - No

Ever had fainting spells?

Fainting - Yes

Yes

Fainting - No

Is the patient pregnant?

Pregnant - Yes

Yes

Pregnant - No

How Far Along in Pregnancy?

Patient's Dental Information & History

Dentist's Name

Dentist's Phone

Date of Last Dental Visit

Dental x-rays taken?

Exray - Yes_es_:signature

Yes

Xray - No

All teeth x-rayed in the past 3 years?

Teeth Xray - Yes

Yes

Teeth Xray - No

Does the patient have dentures?

Dentures - Yes

Yes

Dentures - No

Age of Dentures

Family history of dentures?

Family History of Dentures - Yes

Yes

Family History of Dentures - No

Dissatisfied with how teeth look?

Dissatisfied w Look - Yes

Yes

Dissatisfied w Look - No

Previous orthodontic treatment?

Ortho - Yes

Yes

Ortho - No

Clench or grind teeth?

Clench or Grind - Yes

Yes

Clench or Grind - No

Pain in jaw, face or ears?

Face or Jaw Pain - Yes

Yes

Face or Jaw Pain - No

Jaw makes a clicking sound?

Jaw Click - Yes

Yes

Jaw Click - No

Ever have trouble opening mouth?

Trouble Opening - Yes

Yes

Trouble Opening - No

Unpleasant odor or taste in mouth?

Bad Taste or Odor - Yes

Yes

Bad Taste or Odor - No

Diagnosed with gum disease or pyorrhea?

Gum Disease or Pyorrhea - Yes

Yes

Gum Disease or Pyorrhea - No

Bleeding gums?

Bleeding Gums - Yes

Yes

Bleeding Gums - No

Teeth sensitive to cold?

Sensitive to Cold - Yes

Yes

Sensitive to Cold - No

Teeth sensitive to pressure?

Sensitive to Pressure - Yes

Yes

Sensitive to Pressure - No

Teeth sensitive to heat?

Sensitive to Hot - Yes

Yes

Sensitive to Hot - No

Does food catch between teeth?

Food Between Teeth - Yes

Yes

Food Between Teeth - No

Is there anything else the doctor should be aware of?

Patient Acknowledgment of Receipt of Notice of Privacy Practices

Please review our Notice of Privacy Practices and complete the following following:

I, ______________________________, hereby acknowledge that I have reviewed and received a copy of this office's Notice of Privacy Practices explaining:(Required)

How this office will use and disclose my protected health information.
My privacy rights with regard to my protected health information.
This office's obligations concerning the use and disclosure of my protected health information.

I understand that the Notice of Privacy Practices may be revised from time to time and that I am entitled to receive a copy of any revised Notice of Privacy Practices upon request.

I also understand that if I have any questions or complaints, I may contact:(Required)

You may also contact the Secretary of the U.S. Department of Health and Human Services with any concerns regarding our privacy and security policies and procedures. Please contact our office for information on how to contact the U.S. Department of Health and Human Services.

Today's Date(Required)

MM slash DD slash YYYY

Typed Signature(Required)

Relationship to Patient(Required)

Patient Consent & Authorization for Release of Protected Health Information

Requestor Type

I am the Patient

I am NOT the Patient (I'm a Parent, Caregiver, Etc.)

Requestor's Address(Required)

City(Required)

State(Required)

Zip Code(Required)

I, ______________________________, hereby authorize the release, use, or disclosure of my health information as follows:(Required)

This authorization pertains to the following type of medical information about me:(Required)

I hereby authorize ...(Required)

... to release the above-described information to ...(Required)

I understand that, per my request, this authorization will permit the above-named parties to use or disclose the identified health information for purposes beyond treatment, payment, or healthcare operations as provided by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

I understand that I may revoke this authorization at any time by providing written notification to:(Required)

The revocation will be effective on the date it has been received and processed by the above-named recipient. I understand that the revocation does not apply to actions taken in reliance upon this authorization prior to the effective date of revocation. I also understand that I do not have to sign this authorization in order to receive treatment, payment, or to enroll or be eligible for benefits.

Unless I request in writing otherwise, I understand that this authorization will expire on __________. If I do not specify an expiration date of event, this authorization will expire ninety (90) days from the date on which I signed this authorization.(Required)

MM slash DD slash YYYY

I understand that the information used or disclosed pursuant to this authorization may be subject to redisclosure by the named recipient, and may no longer be protected by HIPAA's privacy rules after the authorized disclosure.

Typed Signature(Required)

Today's Date(Required)

MM slash DD slash YYYY