142 West Winchester Street, Murray, UT
lcdentaldmd@gmail.com
801-266-9034

Call Us: 801-266-4427

Lake City Dental Lake City Dental
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Patient Intake Form

Home / Patient Intake Form

1Patient Information
2Dental Insurance
3Office Agreements
4Medical-Dental History

Patient Information

Name(Required)
MM slash DD slash YYYY
Address(Required)

Contact Information

Responsible Party

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

Dental Insurance

Do you have dental insurance?(Required)
MM slash DD slash YYYY
Insurance Company's Address

INSURANCE ASSIGNENT AND RELEASE

Certification of Insured(Required)
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.
MM slash DD slash YYYY

Office Agreements

Responsible Party Consent Check/Signature(Required)
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.
MM slash DD slash YYYY

Medical History

MM slash DD slash YYYY
AIDS/HIV(Required)
Arthritis(Required)
Asthma(Required)
Bleeding abnormally, with extractions or surgery(Required)
Blood Disease(Required)
Blood Transfusion(Required)
Cancer(Required)
Cortisone Treatments(Required)
Major Surgery in the last year(Required)
Diabetes(Required)
Epilepsy(Required)
Fainting or Dizziness(Required)
Heart Problems(Required)
Hepatitis(Required)
High Blood Pressure(Required)
Pacemaker(Required)
Respiratory Disease(Required)
Rheumatic Fever(Required)
Tuberculosis(Required)
Lupus(Required)
Are there any other conditions we should be aware of?(Required)
Have you ever taken Fosamax, Boniva, Actonel, Atelvia, or Reclast for any reason? Typically for bone density problems (Osteoporosis)(Required)

Women

Are you a female patient?(Required)
Are you pregnant?(Required)
Taking birth control pills?(Required)

Medications

Allergies

Are you allergic to Latex?(Required)
Are you allergic to Penicillin?(Required)

Dental History

MM slash DD slash YYYY
Bleeding Gums(Required)
Tobacco use(Required)
Food collection between teeth(Required)
Jaw pain or tiredness(Required)
Sensitivity to hot(Required)
Sensitivity to cold(Required)
Sensitivity when biting(Required)
Periodontal treatment(Required)
Have you ever had a severe reaction to dental treatment?(Required)
Do you have problems that could be aggravated by reclining in a dental chair?(Required)
Would you like to change anything about your smile?(Required)

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  • 142 West Winchester Street Murray, UT
  • Phone: (801) 266-4427
  • Email: lcdentaldmd@gmail.com
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