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?
Yes No
If yes, explain here.
Have you had orthodontics?
Yes No
If yes, explain here.
Have you ever been treated for gum disease?
Yes No
If yes, explain here.
Is there anything you would change about the appearance of your teeth or smile?
Yes No
If yes, explain here.
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
Yes No
If yes, explain here.
Has a physician recommended you take a Pre-Medication (antibiotics) for dental treatment?
Yes No
If yes, explain here.
Have you ever had a reaction after receiving dental anesthetic?
Yes No
Explain Reaction here.
Have you been hospitalized within the past year?
Yes No
For what condition?
Do you use tobacco (including smokeless)?
Yes No
If yes, explain here.
Do you or have you used controlled substances?
Yes No
If yes, explain here.
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