New Patient Information Form

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

    Contact Information

    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.

    Medical Provider

    Insurance Information

    Primary Insurance Holder

    Secondary Insurance Holder

    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.

    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
    YesNo

    Women: Are you…

    Nursing Taking oral contraceptive

    Are you allergic to any of the following?

    YesNo
    YesNo

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

    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:

    1. – Cancelling or scheduling and appointment
    2. – Inquiring about treatment
    3. – 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.

    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.

    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.