New Patient Information Forms Patient Information Patient Name * Date of Birth * SS# * Patient Address * City * State * Zip * Employer * Home Phone Cell Phone Work Phone Email * Who may we thank for referring you? Dental visits are confirmed by PHONE, TEXT MESSAGE, or EMAIL. Please let us know if you prefer to not receive appointment messages by text or email. Email Yes Text Yes Who is your Medical Doctor/ Pediatrician/ Family Doctor? M.D.'s Phone Pharmacy Name * Required INSURANCE INFORMATION Insured's Employer Insured's Insurance Carrier Policy Holder Policy Holder's Date of Birth Effective Date Insurance ID# or SS# Secondary Insurance Employer Insured's Insurance Carrier Policy Holder Policy Holder's Date of Birth Effective Date Insurance ID# or SS# ASSIGNMENT AND RELEASE OF BENEFITS I certify this information is true and correct to the best of my knowledge. Des Moines River Dental Care has my authorization to adhere to my consents outlined on this form. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assignee to release medical information to secure payment. I understand and agree with what I read* Yes Your Name * Date of Acceptance: * Des Moines River Dental Care complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. * Required Who do you want to share information with? Please keep in mind that this includes anyone on your behalf sharing the responsibility of: Cancelling or scheduling and appointment, inquiring about treatment, paying a bill on my account. *This is required, if you wish to share with no one, please indicate by typing none on each line. Spouse * Parent * Other * I give permission to Des Moines River Dental Care to share my dental history, recommended treatment, and balance info with anyone that I have listed in the Spouse, Parent, or Other fields. I Agree with what I read* Yes Your Name* Today's Date * * Required Reason for visit What Brought you here today?* How long since your last dental visit?* * Required Dental Complications Have you had any dental complications in the past? * YesNo If yes, explain here. * Required Orthodontics Have you had orthodontics? * YesNo If yes, explain here. * Required Gum disease Have you ever been treated for gum disease? * YesNo If yes, explain here. * Required Appearance of your teeth or smile Is there anything you would change about the appearance of your teeth or smile? * YesNo If yes, explain here. * Required Bisphosphonates? Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? * YesNo If yes, explain here. * Required Pre-Medication Has a physician recommended you take a Pre-Medication (antibiotics) for dental treatment? * YesNo If yes, explain here. * Required Reactions Have you ever had a reaction after receiving dental anesthetic? * YesNo If yes, explain here. * Required Hospitalized Have you been hospitalized within the past year? * YesNo If yes, explain here. * Required Women: Are you... Pregnant YesNo If yes, Number of weeks? Nursing YesNo Taking oral contraceptive YesNo Tobacco Do you use tobacco (including smokeless) * YesNo * Required Controlled substances Do you or have you used controlled substances? * YesNo * Required Are you allergic to any of the following? Aspirin Penicillin Codeine Acrylic Metal Latex Sulfa Drugs Local Anesthetics Do you have, or have you had, any of the following? (Select the checkboxes for what you have had) AIDS/HIV PositiveExcessive ThirstMitral Valve Prolapse Alzheimer's DiseaseFainting Spells/DizzinessOsteoporosis AnaphylaxisFrequent CoughPain in Jaw Joints AnemiaFrequent HeadachesParathyroid Disease AnginaGenital HerpesPsychiatric Care Arthritis/GoutGlaucomaRadiation Treatments Artificial Hearth ValveHay FeverRecent Weight Loss Artificial JointHearing ImpairmentRenal Dialysis AsthmaHeart Attack/FailureRheumatic Fever Blood DiseaseHeart MurmurRheumatism Blood TransfusionHeart PacemakerScarlet Fever Breathing ProblemsHeart Trouble/DiseaseShingles Bruise EasilyHemophiliaSickle Cell Disease CancerHepatitis ASinus Trouble ChemotherapyHepatitis B or CSpina Bifida Chest PainsHerpesStomach/Intestinal Disease Cold Sores/Fever BlistersHigh Blood PressureStroke Congenital Heart DisorderHigh CholesterolSwelling of Limbs ConvulsionsHives or RashThyroid Disease Cortisone MedicineHypoglycemiaTonsillitis DiabetesIrregular HeartbeatTuberculosis Drug AddictionKidney ProblemsTumors or Growths Easily WindedLeukemiaUlcers EmphysemaLiver DiseaseVenereal Disease Epilepsy or SeizuresLow Blood PressureYellow Jaundice Excessive BleedingLung Disease Des Moines River Dental Care PLLC NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT I understand that under the Health Insurance Portability & Accountability act of 1996("HIPPA"), I have certain rights to privacy regarding my protected health information(PHI). 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 the treatment, directly and indirectly Obtain payment from third-party payers Conduct normal healthcare operations such as quality assessments and physician certifications I received, read, and understood your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my PHI. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy of this Notice of Privacy Practices. I understood everything I read. * Yes Patient Name or Legal Guardian * Date: * * Required