Today’s Date: __________________

Name: ______________________________________________________

Nickname: _________________________ Male Female

Birthdate: _____/_____/______ SS#: ____________________________

Email:______________________________________________________

Home #: ______________________ Work #: ______________________

Cell #: ____________________ Best Time to Contact You: _________

Preferred Method of Contact: Please choose all that apply.

Home Work Cell Text Email

Address: ____________________________________________________

City: _________________________ State: _______ Zip: ____________

Marital Status: Single Married Divorced Widowed

Whom may we Thank for referring you? _________________________

____________________________________________________________

Previous Dentist: _____________________________________________

Last Visit Date: _____________________________

Apt. #/Floor

PRIMARY DENTAL INSURANCE

Insurance Company Name: ___________________________________

Insurance Co. Address: ______________________________________

Insurance Co. Phone #: __________________ Group #: ___________

Insured’s Name: ____________________________________________

Insured’s Birthdate: ____/_____/_____ ID #: __________________

Insured’s Employer: _________________________________________

In the event of an emergency, whom should we contact?

Name: ____________________________________________________________ Relationship: ____________________________________

Home #: _____________________________ Cell #: _____________________________

SECONDARY DENTAL INSURANCE

Insurance Company Name: ___________________________________

Insurance Co. Address: ______________________________________

Insurance Co. Phone #: __________________ Group #: ___________

Insured’s Name: ____________________________________________

Insured’s Birthdate: ____/_____/_____ ID #: __________________

Insured’s Employer: _________________________________________

EMPLOYER INFORMATION

Employer: __________________________________________________

Occupation: _________________________________________________

How long have you been employed there? ________________________

Employer’s Address: __________________________________________

City: ____________________ State: _______ Zip: ______________

PHYSICIAN’S INFORMATION

Primary Physician’s Name: ___________________________________

Phone #: ________________________________

Are you currently under the care of a physician? Yes No

Please explain: _____________________________________________

___________________________________________________________

DENTAL HISTORY

Why have you come to the dentist today? _________________________________

_____________________________________________________________________

Do you require antibiotics before dental treatment? Y N

Are you currently in pain? Y N

Have you ever had a serious/difficult problem associated

with any previous dental work? Y N

Do you now or have you ever experienced pain/discomfort

in your jaw joint (TMJ/TMD)? Y N

Do you like your smile? Y N

Do your gums ever bleed? Y N

Have you ever had periodontal disease? Y N

Y N Anemia/Radiation Treatment Y N Artificial Bones / Joints / Valves Y N Arthritis Y N Asthma Y N Blood Transfusion Y N Cancer / Chemotherapy Y N Congenital Heart Defect Y N Diabetes Y N Difficulty Breathing Y N Drug / Alcohol Abuse Y N Emphysema / Glaucoma Y N Epilepsy / Seizures / Fainting Spells Y N Fever Blisters / Herpes Y N Heart Attack / Stroke Y N Heart Murmur Y N Heart Surgery / Pacemaker Y N Hemophilia / Abnormal Bleeding Y N Hepatitis Y N High Blood Pressure Y N Low Blood Pressure Y N HIV+ / AIDS Y N Hospitalized for Any Reason Y N Kidney Problems Y N Mitral Valve Prolapse Y N Psychiatric Treatment Y N Rheumatic / Scarlet Fever Y N Severe / Frequent Headaches Y N Shingles Y N Sickle Cell Disease / Traits Y N Sinus Problems Y N Tuberculosis (TB) Y N Ulcers / Colitis Y N Veneral Disease Y N Other ______________________________

Please list any serious medical condition(s) that you have ever had:

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_______________________________________ Are you allergic to any of the following?

Y N Aspirin Y N Erythromycin Y N Penicillin

Y N Codeine Y N Jewelry / Metals Y N Tetracycline

Y N Dental Anesthetics Y N Latex Y N Other

Please list any other drugs / materials that you are allergic to: ___________________

_____________________________________________________________________

Your current physical health is: Good Fair Poor

Are you taking any prescription /

over-the-counter or supplemental drugs? Y N

Please list each one:

_________________________________________________________________

_________________________________________________________________

Do you smoke or use tobacco in any other form? Y N

Have you ever taken Fosamax, or any other bisphosphonate? Y N

Have you been told that you snore or hold your breath

while sleeping or wake up gasping for breath? Y N

FOR WOMEN:

Are you using a prescribed method of birth control? Y N

Are you pregnant? Y N Week #: __________

Are you nursing? Y N

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be

held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to

perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.

_____________________________________________________________________________________ _________________________

Signature Date

Have you ever had any of the following disease or

medical problems? (Please circle the option that applies.)

MEDICAL HISTORY

PHOTOGRAPHY CONSENT/RELEASE

I, _______________________________, hereby grant

permission to Totowa Dental Center to take and use photographs

and/or digital images and/or videos of me for use in educational

and marketing materials. I authorize the use of these images

and/or videos without compensation to me.

_______________________________________ ___________

Signature Date

PATIENT HIPAA CONSENT FORM

I understand that as part of my healthcare, this organization originates and maintains health

records describing my health history, symptoms, examination and test results, diagnoses,

treatment, and any plans for future care or treatment. I understand that this information serves

as:

• a basis for planning my care and treatment

• a means of communication among the many health professionals who contribute to my

care

• a source of information for applying my diagnosis and surgical information to my bill

• a means by which a third-party payer can verify that services billed were actually

provided

• a tool for routine healthcare operations such as assessing quality and reviewing the

competence of healthcare professionals I understand and have been provided with a

Notice of Information Practices that provides a more complete description of information

uses and disclosures.

I understand that I have the right to review the notice prior to signing this consent. I understand

that the organization reserves the right to change their notice and practices and prior to

implementation will mail a copy of any revised notice to the address I’ve provided. I understand

that I have the right to object to the use of my health information for directory purposes. I

understand that I have the right to request restrictions as to how my health information may be

used or disclosed to carry out treatment, payment, or healthcare operations and that the

organization is not required to agree to the restrictions requested. I understand that I may

revoke this consent in writing, except to the extent that the organization has already take action

in reliance thereon.

__________________________________________________________ ________________________

Patient/Parent/Guardian Signature Date

KINDLY GIVE 24 HOURS NOTICE

FOR CANCELLATION OF APPOINTMENTS.

NON-APPEARANCES FOR SCHEDULED APPOINTMENTS

WILL BE SUBJECTED TO A BROKEN APPOINTMENT FEE OF $75.00.

THIS POLICY IS TO INSURE THAT OTHERS ARE GIVEN

THE OPPORTUNITY OF BEING SEEN AND TREATED

IN A TIMELY MANNER. THANK YOU FOR YOUR COOPERATION.

PATIENT SIGNATURE: ___________________________________________________________

DATE: _________________________________________

Changed Your Mind?

OUR CANCELLATION POLICY

Totowa Dental Center

Office Policies

_______________________________________________________________ 360 US-46, Totowa NJ 07512

Phone: (973) 890-0600

_______________________________________________________________

Cancellation Policy:

Kindly give 24 hours notice for cancellation of appointments. Non-appearances for

scheduled appointments will be subjected to a broke appointment fee of $75.00.

This policy is to insure that others are given the opportunity of being seen and treated

in a timely manner. Thank you for your cooperation.

Insurance Policy:

Upon receipt of our patient’s insurance information, Totowa Dental Center will call for a

detailed breakdown on the patient’s behalf. All information attained therein will be used

to help both the patient and the office staff understand the patient’s financial

responsibility. Despite the fact that we receive this information, we would like to make

all patients aware that the breakdown is not a guarantee of coverage until the

procedure is completed and submitted to the insurance. Therefore, any procedure

not covered by the insurance will become the patient’s responsibility.

________________________________________________________________________ _______________________

Patient Signature Date