New Patient | Fesmire Dental Group

Name *

Email *

Email

Confirm Email

Phone *

How do you prefer to be contacted? *

Email
Phone

Emergency Contact Name *

Relationship to Parent

Emergency Contact Phone # *

Patient Address *

Address Line 1

City

State

Zip Code

Sex *

Date of Birth *//

Social Security #

How did you hear about us? *

Occupation *

Employer *

Employer Address *

Address Line 1

City

State

Zip Code

Do you have dental insurance?

Yes
No

Policy Holder's Name *

Name of Employer for the Policy Holder *

Relationship to Patient, unless you are the patient.

Social Security #

Date of Birth *

Insurance Company *

Group # *

Do you have secondary insurance?

Yes
No

Policy Holder's Name *

Relationship to Patient, unless you are the patient.

Social Security #

Date of Birth

Insurance Company

The following information is for our records only and is confidential.

Have you or a member of your family been seen by us before

Yes
No

Date of Last Physical *

Physician's Name

Date of Last Dental Examination *

Date of Last Dental X-Rays *

Previous Dentist Name

City & State of Dentist

example: Nashville, TN

Are you having pain or discomfort at this time? *

Yes
No

Do you feel nervous about having dental treatment? *

Yes
No

Have you ever had a bad experience in a dental office? *

Yes
No

Is there anything you would like to speak to the doctor about in private? *

Yes
No

Have you been a patient in the hospital in the past two weeks? *

Yes
No

Have you been under the care of a medical doctor in the past two years? *

Yes
No

Have you taken any medications or drugs in the past two years? *

Yes
No

Are you taking any medication, vitamins or herbal supplements? *

Yes
No

Have you ever had any extensive bleeding that requiring special treatment? *

Yes
No

Have you ever had a serious head or neck injury? *

Yes
No

If yes, please comment.

Do you take, or have you taken, Phen-Fen or Redux? *

Yes
No

If yes, please comment.

Are you on a special diet? *

Yes
No

Do you use controlled substances? *

Yes
No

AIDS/HIV Positive *

Yes
No

Alzheimer's Disease *

Yes
No

Anaphylaxis *

Yes
No

Anemia *

Yes
No

Angina *

Yes
No

Arthritis/Gout *

Yes
No

Artificial Heart Valve *

Yes
No

Artificial Joint *

Yes
No

Asthma *

Yes
No

Blood Disease *

Yes
No

Blood Transfusion *

Yes
No

Breathing Problems *

Yes
No

Bruise Easily *

Yes
No

Cancer *

Yes
No

Chemotherapy *

Yes
No

Chest Pains *

Yes
No

Cold Sores/Fever Blisters *

Yes
No

Congenital Heart Disorder *

Yes
No

Convulsions *

Yes
No

Yellow Jaundice *

Yes
No

Cortisone Medicine *

Yes
No

Diabetes *

Yes
No

Drug Addiction *

Yes
No

Easily Winded *

Yes
No

Emphysema *

Yes
No

Epilepsy or Seizures *

Yes
No

Excessive Bleeding *

Yes
No

Excessive Thirst *

Yes
No

Fainting Spells/Dizziness *

Yes
No

Frequent Cough *

Yes
No

Frequent Headaches *

Yes
No

Genital Herpes *

Yes
No

Glaucoma *

Yes
No

Hay Fever *

Yes
No

Heart Attach/Failure *

Yes
No

Heart Murmur *

Yes
No

Heart Pacemaker *

Yes
No

Heart Trouble/Disease *

Yes
No

Hemophilia *

Yes
No

Hepatitis A *

Yes
No

Hepatitis B or C *

Yes
No

Herpes *

Yes
No

High Blood Pressure *

Yes
No

High Cholesterol *

Yes
No

Hives or Rash *

Yes
No

Hypoglycemia *

Yes
No

Irregular Heart Beat *

Yes
No

Kidney Problems *

Yes
No

Leukemia *

Yes
No

Liver Disease *

Yes
No

Low Blood Pressure *

Yes
No

Lung Disease *

Yes
No

Mitral Valve Prolapse *

Yes
No

Osteoporosis *

Yes
No

Pain in Jaw Joints *

Yes
No

Parathyroid Disease *

Yes
No

Psychiatric Care *

Yes
No

Radiation Treatments *

Yes
No

Recent Weight Loss *

Yes
No

Renal Dialysis *

Yes
No

Rheumatic Fever *

Yes
No

Rheumatism *

Yes
No

Scarlet Fever *

Yes
No

Sickle Cell Disease *

Yes
No

Sinus Trouble *

Yes
No

Spina Bifida *

Yes
No

Stomach/Intestinal Disease *

Yes
No

Stroke *

Yes
No

Swelling of Limbs *

Yes
No

Thyroid Disease *

Yes
No

Tonsillitis *

Yes
No

Tuberculosis *

Yes
No

Tumors or Growths *

Yes
No

Ulcers *

Yes
No

Venereal Disease *

Yes
No

Have you ever had any serious illness not listed? *

Yes
No

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

Signature *

Date / Time *//

Please initial by each one (initialing states you agree with the conditions):

Please Initial *

We will be glad to file your insurance claim for you. However, you will held responsible for co-pays, previous balances, deductibles, and treatments not covered by your insurance carrier. Dental benefit plans will never pay for completion of your dental care. It is only meant to assist you.

Please Initial *

Broken appointments without prior notification are a burden to all. We do our best to run on time, and we ask that you do the same. We respectfully ask you to give us a 24-hour cancellation notice so that we can schedule other patients. Missed appointments without 24-hour notification are subject to a $40.00 disappointment fee.

Please Initial *

When we verify your benefits, your carrier will give us the general provisions of your coverage plan along with estimated benefit amounts. Actual claims may vary, so we will not know the exact dollar amount until the claim is actually paid.

Please Initial *

As a courtesy, we will be happy to assist you in interpreting and understanding the terms of your dental insurance to the best of our ability. However, these kinds of questions are often better answered by your insurance carrier.

Please Initial *

Fesmire Dental Group does require payment in full for your portion at the time of service. We accept MasterCard, Visa, Discover, American Express, Care Credit, cash, and checks.

Please Initial *

If your insurance company does not pay within 45 days, Fesmire Dental Group reserves the right to request in full for services from you and let you collect the insurance funds that are due to you. This is rare, but it is important that you recognize that the insurance you have is a legal contract between YOU and your insurance company.

Name *

First

Last

Date / Time *//

Signature *

We are very concerned about oral cancer, and conduct screening examinations on every patient.

The incidence of Oral Cancer continues to rise in the USA. The American Cancer Society indicates that in 2007, they expect a remarkable 11% increase in this deadly disease. Alarmingly, 25% of the new oral cancer cases are people that do not have any traditional life style risk factors, such as age and tobacco and alcohol use.

Traditionally, dentists and hygienists have done oral cancer screening with the naked eye, but recently a new technology, the VELscope has received FDA approval. The VEL scope (for Visually Enhance Lesion Scope) will help us pinpoint and identify suspicious tissue at earlier stages before they may become life threatening concerns.

VELscope, similar to the other early detection procedures like colonoscopy, mammography, 'PAP smear and PSA exam, is a painless, non invasive blue light that is shined into the patients mouth. The images are viewed through the back of the VELscope hand piece and the hygienist or dentist may find tissue abnormalities at an earlier stage. Before the exam, the room is darkened and much like "desert storm night vision technology", the clinician can see change􀀕 in tissue that may not be visible to the eye. These detected changes can range from something minor to something of greater concern that may require further examination and follow up.

The VElscope testing is in addition to our traditional visual oral cancer screening and will add only a few minutes to the entire exam. However, the VELscope exam may or may not be covered by dental insurances. The fee for this enhanced examination is $ 20.00 . As part of our standard of care and because we care about you, we strongly recommend that you choose this additional screening procedure.

Please sign the area below to accept the financial responsibility for this procedure. Once again, we feel this breakthrough technology is very important to the enhanced quality of care we can offer to our patients. Thank you for your kind consideration.

I authorize the office to perform the VELscope examination *

Yes
No

If you select NO, you may still request the screening at any future appointments.

Name *

First

Last

Date / Time *//

Signature *

Patient HIPPA CONSENT FORM

I understand that as part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as:

• a basis for planning my care and treatment

• a means of communication among the many health professionals who contribute to my care a source of information for applying my diagnosis and surgical information to my bill

• a means by which a third-party payer can verify that services billed were actually provided

• and a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professional

I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the right to review the notice prior to signing this consent. I understand that the organization reserves the right to change their notice and practices and prior to implementation will mail a copy of any revised notice to the address I've provided. I understand that I have the right to object to the use of my health information for directory purposes. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that the organization is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already take action in reliance thereon.

Name *

First

Last

Date / Time *//

Signature *

If you aren't the patient, what is your relationship to the patient?

New Patient Registration & Health History