142 West Winchester Street, Murray
, UT
lcdentaldmd@gmail.com
801-266-9034
Call Us: 801-266-4427
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Patient Intake Form
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Patient Intake Form
1
Patient Information
2
Dental Insurance
3
Office Agreements
4
Medical-Dental History
Patient Information
Name
(Required)
First
Last
Preferred Name
Date of Birth
(Required)
MM slash DD slash YYYY
Age
(Required)
Social Security #
Sex
(Required)
Female
Male
Marital Status
(Required)
Single
Married
Other
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)
Email
Work Phone
How is the best way to contact you?
Phone
Email
Text
Emergency Contact
Emergency Contact Phone
Responsible Party
Is the Responsible Party someone other than the Patient?
(Required)
Yes
No
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
Female
Male
Other
Prefer not to say
Dental Insurance
Do you have dental insurance?
(Required)
Yes
No
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
MM slash DD slash YYYY
Office Agreements
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
No
Arthritis
(Required)
Yes
No
If yes, when:
Asthma
(Required)
Yes
No
Bleeding abnormally, with extractions or surgery
(Required)
Yes
No
Blood Disease
(Required)
Yes
No
Blood Transfusion
(Required)
Yes
No
Cancer
(Required)
Yes
No
If yes, when:
Cortisone Treatments
(Required)
Yes
No
Major Surgery in the last year
(Required)
Yes
No
If yes, when:
Diabetes
(Required)
Yes
No
Epilepsy
(Required)
Yes
No
Fainting or Dizziness
(Required)
Yes
No
Heart Problems
(Required)
Yes
No
If yes, when:
Hepatitis
(Required)
Yes
No
If yes, when:
High Blood Pressure
(Required)
Yes
No
Pacemaker
(Required)
Yes
No
Respiratory Disease
(Required)
Yes
No
Rheumatic Fever
(Required)
Yes
No
Tuberculosis
(Required)
Yes
No
Lupus
(Required)
Yes
No
Are there any other conditions we should be aware of?
(Required)
Yes
No
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
No
Women
Are you a female patient?
(Required)
Yes
No
Are you pregnant?
(Required)
Yes
No
If yes, due date:
Taking birth control pills?
(Required)
Yes
No
Medications
List any current medications and why you are taking them:
Allergies
Are you allergic to Latex?
(Required)
Yes
No
Are you allergic to Penicillin?
(Required)
Yes
No
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
No
Tobacco use
(Required)
Yes
No
If yes, what type and how often:
Food collection between teeth
(Required)
Yes
No
How are your eating habits?
(Required)
Poor
Fair
Good
Excellent
Jaw pain or tiredness
(Required)
Yes
No
Sensitivity to hot
(Required)
Yes
No
Sensitivity to cold
(Required)
Yes
No
Sensitivity when biting
(Required)
Yes
No
Periodontal treatment
(Required)
Yes
No
Have you ever had a severe reaction to dental treatment?
(Required)
Yes
No
If yes, please explain:
Do you have problems that could be aggravated by reclining in a dental chair?
(Required)
Yes
No
If yes, please explain:
Would you like to change anything about your smile?
(Required)
Yes
No
If yes, please explain:
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