New Patient Information

Personal Information

  • Mr. Mrs. Ms. Miss
  • (Last)
  • (First)
  • (MI)
  • What name shall we call you?
  • Date of Birth
  • Sex
  • Male Female
  • Home address
  • City
  • State
  • Zip
  • E-mail Address
  • Home #
  • Cell #
  • Employer
  • Occupation
  • Spouse Name
  • Children(s) names
  • Parent /guardian name if minor
  • Emergency contact
  • Relation
  • Telephone
  • Who may we thank for referring you?
  • Are you a full-time college student? Name of school and city:

Insurance Information

  • Name of Insurance
  • Subscribers Name
  • DOB
  • ID #
  • Group #
  • Phone# of Insurance
  • Employer Name




HEALTH/DENTAL INFORMATION

  • DO YOU HAVE OR HAVE YOU EVER HAD ANY OF THE FOLLOWING? CHECK YES OR NO
  • Yes No Yes No Yes No
    LOW BLOOD SUGAR
    CANCER
    DIGESTIVE PROBLEMS
    DIABETES
    LATEX ALLERGY
    EATING DISORDERS
    HAY FEVER, ALLERGIES
    HIV POSITIVE
    ARE YOU PREGNANT
    ASTHMA
    AIDS
    RHEUMATIC FEVER
    CIRCULATORY PROBLEM
    SPINAL FUSION
    MITRAL VALVE PROLAPSE
    HEPATITIS A
    ARTIFICIAL JOINTS
    HEART DISEASE
    HEPATITIS B
    OSTEOPOROSIS
    HEART ATTACK
    HEPATITIS C
    SINUS PROBLEMS
    HEART PACE MAKER
    JAUNDICE
    ANEMIA
    HEART SURGERY
    LUNG PROBLEMS
    BLOOD DISORDER
    STROKE
    TUBERCULOSIS
    EXCESSIVE BLEEDING
    HIGH BLOOD PRESSURE
    EPILEPSY / SEIZURE
    FAINTING / BLACKOUTS
    LOW BLOOD PRESSURE
    BLOOD TRANSFUSION
    NERVOUS DISORDER
    HEART VALVE REPLACEMENT
    FACIAL / HEAD INJURY
    HEADACHES / MIGRAINES
    SEVERE SPINAL STENOSIS
    RADIATION
    KIDNEY PROBLEMS
    THYROID PROBLEMS
    CHEMOTHERAPY
    GLAUCOMA / EYE ISSUE
    HIGH CHOLESTEROL
    MALIGNANCIES
    ULCERS
  • DO YOU HAVE ANY OTHER DISEASES OR CONDITIONS NOT LISTED ABOVE? IF YES PLEASE LIST:
  • DO YOU HAVE ALLERGIES TO ANY OF THE FOLLOWING? PLEASE CHECK ALL THAT APPLY
  • ASPIRIN CODEINE ANESTHETICS XYLOCAINE NOVOCAINE LIDOCAINE SEDATIVES SULFA PENICILLIN ERYTHROMYCIN
  • OTHER:
  • LIST ALL MEDICATIONS CURRENTLY BEING TAKEN OR A PRINTED COPY OF YOUR LIST:
  • NAME AND PHONE # OF PHYSICIAN:
  • HAVE YOU BEEN HOSPITALIZED IN THE LAST YEAR? IF YES, EXPLAIN
  • DO YOU CONSUME ALCOHOL OR USE TOBACCO?
  • Yes No
  • IN WHAT QUANTITIES
  • HAVE YOU EVER BEEN TREATED BY A PERIODONTIST, ORTHODONTIST OR ENDODONTIST?
  • Yes No
  • IF YES, EXPLAIN
  • ARE YOU HAPPY WITH THE APPEARANCE OF YOUR TEETH?
  • Yes No
  • REASON FOR THIS DENTAL VISIT:
  • DATE OF YOUR LAST DENTAL CLEANING
  • WAS YOUR LAST DENTAL CLEANING AT THIS OFFICE?
  • Yes No
  • HAVE YOU NOTICED ANY OF THE FOLLOWING?
  • Yes No Yes No
    DISCOMFORT IN FACE, HEAD, NECK, JAW
    JAW CLICKING OR POPPING
    LOOSE TEETH
    SWELLING OR LUMPS IN MOUTH
    FOOD CAUGHT BETWEEN TEETH
    BLEEDING OR SORE GUMS
    SENSITIVITY TO SWEETS, HOT OR COLD
    RECURRING SORE IN OR AROUND MOUTH
    TEETH TENDER TO CHEWING




  • To avoid any misunderstanding concerning your dental insurance, we wish for our patients to know that all professional services rendered will be out of network and charged directly to the patient who is responsible for the payment of said services. We do not render serviceor treatment on the basis that the insurance company will pay our fees unless a pre-determination of benefits has been established in writing. However, we will file the necessary insurance forms for all treatment and services that have been completed. Payment is due when the service is rendered unless other arrangements have been made. If you must change a scheduled appointment, please inform the office within 2 business days of your scheduled appointment to avoid a charge to your account.
  • I hereby authorize Chase Hall, DMD to take radiographic X-rays, study models, photographs or any other diagnostic aid deemed necessary to make a thorough diagnosis for my dental care. I also authorize the doctor to prescribe necessary forms of medication, and to perform any treatment that may be indicated and agreed upon regarding my dental care.
  • I understand my rights to privacy regarding my protected health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that this information can and will be used to provide and coordinate my treatment among consulting health/dental care providers who may be involved in that treatment directly and indirectly. I further authorize the release of any information regarding the diagnosis and records of treatment to my insurance company. The release of such information to the insurance company is solely for the purpose of facilitating the billing and reimbursement of treatment directly to the dentist for insurance benefits under which I am entitled. I understand the responsibility for payment of services rendered for myself and my family are due and payable at the time the services are performed.
  • I also give my consent to receive emails and text messages from Hall Family Dental Care regarding appointment reminders and other correspondence regarding my dental care.
  • Under the requirements for HIPAA we are not allowed to give your protected health information to anyone without your consent. If you wish to have a family member or someone close to you have access to your private health information, please indicate below.
  • You May Disclose My Information To The Following
  • Do Not Disclose My Information To Anyone But Me
  • 1
  • Relationship to Patient:
  • Date
  • 2
  • Relationship to Patient:
  • Date
  • MY SIGNATURE CONFIRMS THAT I UNDERSTAND ALL HIPAA, FINANCIAL AND COMMUNICATION POLICIES AS OUTLINED ABOVE AND THAT THE HEALTH AND DENTAL INFORMATION THAT I HAVE PROVIDED IS CORRECT TO THE BEST OF MY KNOWLEDGE.
  • PATIENT NAME
  • Date
  • SIGNATURE OF PATIENT OR RESPONSIBLE PARTY:

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