Image

Patient Information

Name(Required)

First Last

Preferred Name

Date of Birth(Required)

MM slash DD slash YYYY

Age(Required)

Social Security #

Sex(Required)

Marital Status(Required)

Spouse / Legal Guardian if Minor

Address(Required)

Street Address City State ZIP / Postal Code

Employer(Required)

Occupation(Required)

Hobbies

How did you hear about us?(Required)

Contact Information

Home Phone

Cell Phone (If different from home)

Work Phone

How is the best way to contact you?

Emergency Contact

Emergency Contact Phone

Responsible Party

Is the Responsible Party someone other than the Patient?(Required)

Yes

Who is responsible for this account?(Required)

Relationship to Patient?(Required)

SS# of Responsible Party

Address(Required)

Street Address City State ZIP / Postal Code

Phone(Required)

Gender

Dental Insurance

Do you have dental insurance?(Required)

Yes

Name of Insured(Required)

Relationship to Patient(Required)

SS #

Date of Birth(Required)

MM slash DD slash YYYY

Insurance Company(Required)

Policy ID #(Required)

Group #

Insurance Company's Address

Street Address City State ZIP / Postal Code

Insurance Company Phone

INSURANCE ASSIGNENT AND RELEASE

Certification of Insured(Required)

I certify and this checkbox acts as my consenting signature.

I certify that I and/or my dependent(s) have insurance coverage and assign directly to Dr. Steven J. Smith and Dr. Morgan J. Smith all insurance benefits payable to me for services rendered. I understand that the estimates given are based on the information provided by myself and the insurance company. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

Date Certified/Signed(Required)

MM slash DD slash YYYY

Office Agreements

For new patients only

Please select your preferred method to receive billing statements below.

Mail

Email (please provide below the current email address)

Text (please sign consent below)

Email (please provide below the current email address)

Consent to text messaging

I consent to receive billing statements by text from Lake City Dental. I understand that standard messaging and data rates through my carrier may apply . I can contact the office to opt out at any point

Phone Number

Signature

Date

MM slash DD slash YYYY

Responsible Party Consent Check/Signature(Required)

I have read and understand the contents of this agreement.

1. We are a HIPAA compliant office. We are required by applicable federal and state law to maintain the privacy of your health information. We will use and disclose health information about you for treatment, payment and healthcare operations.

2. Payment in full for all charges is required at the time of service. All delinquent accounts (30 days or older) are subject to service charges of 18%. In the event your account is turned over to a collection agency, you will be responsible for payment of any collection costs (40%) and attorney fees in addition to the balance owed. Any account turned over to a collection agency forfeits and reverses any special fees and/or discounts given.

3. In the even that any problem or dispute arising under this Agreement is not satisfactorily resolved, responsible party and Smith Family Dental will arbitrate such problem or dispute. The arbitration will be conducted by the American Arbitration Association under the Western Rules of Arbitration. Responsible Party and Smith Family Dental agree that the arbitration results shall be binding on both parties in any subsequent litigation or dispute.

Date of Consent/Signature(Required)

MM slash DD slash YYYY

Medical History

Medical Physician's Name

Date of last visit

MM slash DD slash YYYY

AIDS/HIV(Required)

Yes

Arthritis(Required)

Yes

If yes, when:

Asthma(Required)

Yes

Bleeding abnormally, with extractions or surgery(Required)

Yes

Blood Disease(Required)

Yes

Blood Transfusion(Required)

Yes

Cancer(Required)

Yes

If yes, when:

Cortisone Treatments(Required)

Yes

Major Surgery in the last year(Required)

Yes

If yes, when:

Diabetes(Required)

Yes

Epilepsy(Required)

Yes

Fainting or Dizziness(Required)

Yes

Heart Problems(Required)

Yes

If yes, when:

Hepatitis(Required)

Yes

If yes, when:

High Blood Pressure(Required)

Yes

Pacemaker(Required)

Yes

Respiratory Disease(Required)

Yes

Rheumatic Fever(Required)

Yes

Tuberculosis(Required)

Yes

Lupus(Required)

Yes

Are there any other conditions we should be aware of?(Required)

Yes

If yes, please explain:

Have you ever taken Fosamax, Boniva, Actonel, Atelvia, or Reclast for any reason? Typically for bone density problems (Osteoporosis)(Required)

Yes

Women

Are you a female patient?(Required)

Yes

Are you pregnant?(Required)

Yes

If yes, due date:

Taking birth control pills?(Required)

Yes

Medications

List any current medications and why you are taking them:

Allergies

Are you allergic to Latex?(Required)

Yes

Are you allergic to Penicillin?(Required)

Yes

Other

Dental History

Reason for today's visit

Reason(s) for changing Dentists

Date of last dental visit

MM slash DD slash YYYY

Bleeding Gums(Required)

Yes

Tobacco use(Required)

Yes

If yes, what type and how often:

Food collection between teeth(Required)

Yes

How are your eating habits?(Required)

Jaw pain or tiredness(Required)

Yes

Sensitivity to hot(Required)

Yes

Sensitivity to cold(Required)

Yes

Sensitivity when biting(Required)

Yes

Periodontal treatment(Required)

Yes

Have you ever had a severe reaction to dental treatment?(Required)

Yes

If yes, please explain:

Do you have problems that could be aggravated by reclining in a dental chair?(Required)

Yes

If yes, please explain:

Would you like to change anything about your smile?(Required)

Yes

If yes, please explain:

Call Us: 801-266-4427

Patient Information

Contact Information

Responsible Party

Dental Insurance

INSURANCE ASSIGNENT AND RELEASE

Office Agreements

Medical History

Women

Medications

Allergies

Dental History

Image Shortcode