New Patient Information Form – Des Moines River Dental Care

Before your first appointment with us, we require some information in order to provide you with the highest quality treatment plan. For your convenience, we offer an online form you can submit beforehand, or you can fill it out in person the same day you visit. Save time by filling out the form below!

Patient Information

Basic Information

Patient Name: Date of Birth: SS#: Who may we thank for referring you?

Contact Information

Patient Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Email:

Contact Method

Dental visits are confirmed by PHONE, TEXT MESSAGE, or EMAIL. Please let us know if you prefer not to receive appointment messages by text or email.

No Emails No Texts

Medical Provider

Who is your Medical Doctor/ Pediatrician/ Family Doctor? Pharmacy Name: M.D.’s Phone:

Insurance Information

Primary Insurance Holder

Insured’s Employer: Insured’s Insurance Carrier: Policy Holder: Policy Holder’s Date of Birth: Effective Date: Insurance ID#:

Secondary Insurance Holder

Insured’s Employer: Insured’s Insurance Carrier: Policy Holder: Policy Holder’s Date of Birth: Effective Date: Insurance ID#:

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 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.

Health History What brought you here today? How long since your last dental visit?

Have you had any dental complications in the past? YesNo If yes, explain here.

Have you had orthodontics? YesNo If yes, explain here.

Have you ever been treated for gum disease? YesNo If yes, explain here.

Is there anything you would change about the appearance of your teeth or smile? YesNo If yes, explain here.

Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? YesNo If yes, explain here.

Has a physician recommended you take a Pre-Medication (antibiotics) for dental treatment? YesNo If yes, explain here.

Have you ever had a reaction after receiving dental anesthetic? YesNo Explain Reaction here.

Have you been hospitalized within the past year? YesNo For what condition?

Women: Are you…

Pregnant? Pregnant If yes, number of weeks? Nursing? Nursing Taking oral contraceptive? Taking oral contraceptive

Are you allergic to any of the following?

Aspirin Penicillin Codeine Acrylic Metal Latex Sulfa Drugs Local Anesthetics

Do you use tobacco (including smokeless)? YesNo If yes, explain here.

Do you or have you used controlled substances? YesNo If yes, explain here.

Do you have, or have you had, any of the following? (Select the checkboxes for what you have had)

AIDS/HIV Positive Excessive Thirst Mitral Valve Prolapse Alzheimer's Disease Fainting Spells/Dizziness Osteoporosis Anaphylaxis Frequent Cough Pain in Jaw Joints Anemia Frequent Headaches Parathyroid Disease Angina Genital Herpes Psychiatric Care Arthritis/Gout Glaucoma Radiation Treatments Artificial Hearth Valve Hay Fever Recent Weight Loss Artificial Joint Hearing Impairment Renal Dialysis Asthma Heart Attack/Failure Rheumatic Fever Blood Disease Heart Murmur Rheumatism Blood Transfusion Heart Pacemaker Scarlet Fever Breathing Problems Heart Trouble/Disease Shingles Bruise Easily Hemophilia Sickle Cell Disease Cancer Hepatitis A Sinus Trouble Chemotherapy Hepatitis B or C Spina Bifida Chest Pains Herpes Stomach/Intestinal Disease Cold Sores/Fever Blisters High Blood Pressure Stroke Congenital Heart Disorder High Cholesterol Swelling of Limbs Convulsions Hives or Rash Thyroid Disease Cortisone Medicine Hypoglycemia Tonsillitis Diabetes Irregular Heartbeat Tuberculosis Drug Addiction Kidney Problems Tumors or Growths Easily Winded Leukemia Ulcers Emphysema Liver Disease Venereal Disease Epilepsy or Seizures Low Blood Pressure Yellow Jaundice Excessive Bleeding Lung Disease

Information Disclosure

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 Your Name Today’s Date

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 Patient Name or Legal Guardian Date: