New Patient Information Forms

    Patient Information
    1. Dental visits are confirmed by PHONE, TEXT MESSAGE, or EMAIL.
    2. Please let us know if you prefer to not receive appointment messages by text or email.
    3. Yes
    4. Yes

    * Required

    INSURANCE INFORMATION
    1. Effective Date
    2. Insured's Insurance Carrier
    3. Effective Date
    4. ASSIGNMENT AND RELEASE OF BENEFITS
    5. 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.
    6. Yes
    7. 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?
    1. Please keep in mind that this includes anyone on your behalf sharing the responsibility of:
    2. Cancelling or scheduling and appointment, inquiring about treatment, paying a bill on my account.
    3. *This is required, if you wish to share with no one, please indicate by typing none on each line.
    4. 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.
    5. Yes

    * Required

    Reason for visit

    * Required

    Dental Complications
    1. YesNo

    * Required

    Orthodontics
    1. YesNo

    * Required

    Gum disease

    * Required

    Appearance of your teeth or smile

    * Required

    Bisphosphonates?

    * Required

    Pre-Medication

    * Required

    Reactions

    * Required

    Hospitalized

    * Required

    Women: Are you...
    Tobacco
    1. YesNo

    * Required

    Controlled substances
    1. 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
    1. 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:
    2. Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in the treatment, directly and indirectly
    3. Obtain payment from third-party payers
    4. Conduct normal healthcare operations such as quality assessments and physician certifications
    5. 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.
    6. Yes

    * Required