New Patient Form

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Company

Welcome and thank you for selecting Sandia Dental Care and our dental health care team.
We strive to provide our patients the best possible dental care. If you have any questions or need assistance, please ask us. We will be happy to help.

I was referred by:

Mailer Billboard Website Google Radio Other/Name

Other/Name

Patient Information

Name

Gender:

Male Female

Birth Date

Address

State

E-mail address

Date

Status

Minor Single Married Separated Divorced Widowed

Soc. Sec. #

City

Zip

I want to receive future news and updates from Sandia Denta

Yes No

Home Phone

Mobile Phone

Work Phone

Responsible Party Information
(Skip if this portion does not apply to you)

Name

Relationship to Patient

DOB

Driver’s Lic. #

Soc. Sec. #

Address

State

Employer

City

Zip

Occupation

Home Phone

Mobile Phone

Work Phone

Ext.

Prefer Calls at

Home Cell Work

In Case of Emergency

Contact name

Relationship

Home Phone

Work Phone

Ext.

Dental Insurance Information

Policy Holder Name:

DOB

Soc. Sec. #

DOB

Soc. Sec. #

Insurance Plan

Employer

Insurance Address

Insurance Ph#

Insurance Plan

Employer

Insurance Address

Insurance Ph#

Group #

Payor ID

Group #

Payor ID

dental insurance information

I authorize the dentist to release any information, including the diagnosis and any record of treatment or examination, rendered to me or my child during the period of such dental care to third-party payers and/or other health practitioners.

I authorize and request my insurance company to pay directly to the dentist any insurance benefits otherwise payable to me. 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 the services rendered on my behalf or my dependents.

I request and authorize the dental staff to perform necessary dental services for my child or dependent, including but not limited to, X-rays and administration of anesthetics that are deemed advisable by the doctor, whether or not I am present at the actual appointment when treatment is rendered.

Date *

Medical History
Although dentistry treats primarily the area in and around your mouth, your mouth is a part of your entire body. We believe in the importance of treating the patient holistically. Therefore, other health problems or medications that you may be taking could be relevant to your dental care. Thank you for answering the following questions.

Are you under a physician’s care now?

Yes No

If Yes, please explain

Physicians name

Physicians address

Physicians phone

Have you ever been hospitalized or had a major operation?

Yes No

Have you ever had a serious head/neck injury?

Yes No

Are you taking any medications, vitamins, pills or drugs?

Yes No

If Yes, please explain

Please list or provide copy

Do you have acid reflux?

Yes No

Have you taken Phen-Fen or Redux?

Yes No

Snoring?

Yes No

Sleep apnea?

Yes No

Do you use tobacco?

Yes No

Do you use controlled substances?

Yes No

Women

Are you pregnant or trying to get pregnant?

Yes No

Taking oral contraceptives?

Yes No

Nursing?

Yes No

Are you allergic to any of the following?

Are you allergic to any of the following?

Aspirin Penicillin Codeine Acrylic Metal Latex Tetracycline Erythromycin Sedatives Local anesthetics

Other please explain

Do you have, or have you had, any of the following? Please check all that apply and circle the appropriate diagnosis.

Do you have, or have you had, any of the following? Please check all that apply and circle the appropriate diagnosis.

AIDS/HIV positive

Alzheimer’s disease

Anaphylaxis

Anemia

Angina

Arthritis/gout

Artificial heart valve

Artificial joint

Asthma

Blood disease

Blood transfusion

Breathing problems

Bruise easily

Cancer

Chemotherapy

Chest pains

Cold sores

Congenital heart disorder

Do you have, or have you had, any of the following? Please check all that apply and circle the appropriate diagnosis.

Convulsions

Diabetes

Drug addiction

Easily winded

Emphysema

Epilepsy or seizures

Excessive bleeding

Excessive thirst

Frequent cough

Frequent diarrhea

Frequent headaches

Genital herpes

Glaucoma

Hay fever

Heart attack/failure

Heart murmur

Heart pace maker

Hemophilia

Do you have, or have you had, any of the following? Please check all that apply and circle the appropriate diagnosis.

Hepatitis A

Hepatitis B or C

Herpes

High blood pressure

Hives or rash

Hypoglycemia

Irregular heartbeat

Kidney problems

Leukemia

Liver disease

Low blood pressure

Lung Disease

Mitral valve prolapse

Pain in jaw joints

Parathyroid disease

Psychiatric care

Radiation treatments

Recent weight loss

Do you have, or have you had, any of the following? Please check all that apply and circle the appropriate diagnosis.

Heart trouble/disease

Renal disease

Rheumatic fever

Scarlet fever

Rheumatism

Shingles

Sickle cell disease

Sinus trouble

Spinal bifida

Stomach/intestinal disease

Stroke

Swelling of limbs

Thyroid disease

Tonsillitis

Tuberculosis

Ulcers

Venereal disease

Yellow jaundice

Fainting spells

Have you ever had a serious illness NOT listed above?

Yes No

If Yes, please explain

To the best of my knowledge, I have answered the questions on this form accurately. I understand that it is my responsibility to inform the dental office promptly of any changes in overall health or medical status.

Date *

Dental History

Reason for visit today?

Date of Last Dental Visit

How often do you have dental examinations?

How often do you floss?

Previous Dentist’s Name:

How often do you brush your teeth?

What dental aids do you use?(Proxybrush, rinses, picks etc.)

Are any of your teeth sensitive to:

Hot or cold?

Yes No

Sweets?

Yes No

Biting or chewing?

Yes No

Do you notice any mouth odor or bad taste?

Yes No

Do you frequently get cold sores, blisters or any other oral lesions?

Yes No

Do your gums bleed or hurt?

Yes No

Does food tend to become caught in your teeth?

Yes No

If yes, where

Have your parents experienced gum disease or tooth loss?

Yes No

Have you noticed any loose teeth or change in your bite?

Yes No

Do you:

Clench or grind your teeth while awake?

Yes No

Hold foreign objects with your teeth?

Yes No (pencils, pipe, pins, nails, fingernails)

Clench or grind your teeth while you sleep?

Yes No

Mouth breathe while awake or asleep?

Yes No

Bite your lips or cheeks regularly?

Yes No

Have tired jaws, especially in the morning?

Yes No

Have you ever had:

Orthodontic treatment?

Yes No

Are you interested in straightening your teeth?

Yes No

Your teeth ground or the bite adjusted?

Yes No

Traditional Braces?

Yes No

Oral surgery?

Yes No

A bite plate or mouth guard?

Yes No

If yes, describe

Do you wear retainers?

Yes No

Periodontal treatment?

Yes No

A serious injury to the mouth?

Yes No

If yes, describe

Have you ever experienced:

Clicking or popping of the jaw?

Yes No

Joint, ear or side of face pain?

Yes No

Difficulty in closing mouth?

Yes No

Are you satisfied with your Teeth’s appearance?

Yes No

Do you feel nervous about having dental treatment?

Yes No

If so, what is your biggest concern?

Is there anything else about having dental treatment that you would like us to know?

Office Policies
Thank you for choosing Sandia Dental Care for your dental care needs. We believe it’s important to share our policies with our patients in advance. As always, we are pleased to answer any questions you may have or explain the treatment process in greater detail. Please read thoroughly and sign below indicating that you understand these policies and agree to comply with them. We welcome your questions and comments and are committed to providing excellent dental care services to all our patients. We appreciate the confidence you place in us.

Insurance
We may accept assignment of insurance benefits from your primary carrier after your second visit. Your coinsurance portion, including any deductible, is due at the time of service. Your co-insurance or co-payment is calculated on the information provided by your carrier at the time of estimate. Please note that your insurance policy is a contract between you and your insurance company. We accept assignment of benefits as a courtesy to our patients. Any claim not paid by your insurance carrier within 60 days will be billed to the patient.

Missed Appointments
Please help us serve you and our other patients better by keeping your scheduled appointments. Our answering machine does not accept cancellations. We prefer to speak with you in person and require 24-hour advanced notice to reschedule or cancel appointments. If you DO NOT give a 24-hour notice to reschedule or cancel your appointment there WILL BE a $60.00 fee charged to your account.

Delinquent Accounts
In the event payments are not received by agreed upon dates, a 1.75% late charge (21% APR) may be added to the delinquent account. Attorney’s fees and collection fees incurred to settle any outstanding balance are the responsibility of the patient. There will be a $25.00 fee for any returned check.

Methods of Payment
Payment for services is expected at the time of treatment unless prior arrangements have been made. For your convenience we accept: Cash, Check, Credit Card, Care Credit (MasterCard, Visa, Discover, and American Express).

Check here if you’d like to learn more about Care Credit® (Deferred interest financing program)

Date *

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
*You May Refuse to Sign This Acknowledgement*

Your name

have received a copy of this office’s Notice of Privacy Practices.

Date

Office purposes only

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but
acknowledgement could not be obtained because:

Office purposes only

Individual refused to sign

Communication barriers prohibited obtaining the acknowledgement

An emergency situation prevented us from obtaining acknowledgement

Other (Please Specify)

Other

Sandia Dental Care
6800 Montgomery Blvd. N.E. Suite C
Albuquerque, New Mexico 87109
Phone (505) 884-8000

DENTAL TREATMENT CONSENT FORM

For your convenience, we make available this generalized dental consent form for you to review and sign. Please do not hesitate to ask our dental staff any questions you may have.

DRUGS AND MEDICATIONS
I understand that local anesthetics, antibiotics, and pain medications can cause allergic reactions causing redness and swelling of tissues, pain, itching, vomiting, and or anaphylactic shock (severe allergic reaction).

PERIODONTAL LOSS (TISSUE & BONE)
I understand that serious gum problems can lead to bone infection or bone loss and that it can lead to the loss of my teeth. Alternative treatments include gum surgery, replacement and or extractions. I understand that undertaking any dental procedures may have a future adverse effect on my periodontal condition.

ENDODONTIC TREATMENT (ROOT CANAL)
I realized there is no guarantee that root canal treatment will save my tooth, and that complications can occur from the treatment, and that occasionally metal objects are cemented in the tooth or extend through the root, which does not necessarily affect the success of the treatment. I understand that occasionally additional surgical procedures may be necessary following root canal treatment (apicoectomy).

CROWNS, BRIDGES AND CAPS
I understand that sometimes it is not possible to match the color of natural teeth exactly with artificial teeth. I further understand that I may be wearing temporary crowns, which may come off easily and that I must be careful to ensure that they are kept on until the permanent crowns are delivered. I realize the final opportunity to make changes in my new crown, bridge, or cap including shape, fit, size, and color will be before cementation.

REMOVAL OF TEETH
If the teeth are savable or restorable, the alternatives to removal of teeth are root canal therapy, crowns and periodontal surgery. I understand removing teeth does not always remove all the infection, if present and it may be necessary to have further treatment. I understand the risks involved in having teeth removed, some of which are pain, swelling, spread of infection dry socket, loss of feeling in my teeth lips, tongue and surrounding tissue (paresthesia) that can last for an indefinite period of time (days or months) ,or fractured jaw. I understand I may need further treatment by a specialist or even hospitalization if complications arise during or following treatment, the cost of which is my responsibility.

DENTURE, COMPLETE OR PARTIAL
I realize that full or partial dentures are artificial, constructed of plastic, metal, and or porcelain. The problems of wearing these appliances include looseness, soreness, and possible breakage. I realize the final opportunity to make changes in my new dentures (including shape, fit, size, placement, and color) will be the “teeth in wax” try-in visits. I understand that most dentures require relining approximately three to twelve months after initial placement. The cost for this procedure is not included in the initial denture fee.

CHANGE IN TREATMENT PLAN
I understand that during or following treatment it may be necessary to change or add procedure because of conditions found on the teeth that were not discovered during examination, the most common being root canal therapy following routine restorative procedure.

I understand that dentistry is not an exact science and that, therefore, reputable practitioners cannot guarantee results. I acknowledge that no guarantee or assurance has been made to me by anyone regarding the dental treatment that I have requested and authorized for my minor child or myself. I have had full opportunity to discuss and ask questions regarding the dental treatment, and all questions have been answered to my satisfaction.

Date *