New England Smile

New Patient Registration - Adult

PATIENT INFORMATION

" * " denotes required field

First Name

Last Name

Date of Birth

Street Address

City

State

Zip Code

Primary contact phone #

Alternate contact phone #

Email Address:

How did you hear about us?

RESPONSIBLE PARTY

Who is the responsible party? Self Parent Guardian?

INSURANCE INFORMATION

Do you have Dental Insurance? Yes No

PERSONAL EVALUATION

On a scale of 1-10 how do you feel about your teeth and your smile (1-worst, 10-best)

Do you have any known problems or concerns about your teeth or gums?
Yes No

If yes, please explain

Are your teeth crooked or crowded and is that a concern?
Yes No

If yes, please explain

Do you have any spaces between your teeth that bother you?
Yes No

If yes, please explain

IS THERE ANY OTHER MEDICAL OR DENTAL INFORMATION OR DETAILS YOU WANT TO ADD?

APPOINTMENT CANCELLATIONS

As a courtesy, we make every effort to confirm your appointment one day in advance. However, it should be noted it is your responsibility to keep all appointments. We request a MINIMUM OF 24 HOURS to change or cancel an appointment. A fee may be incurred for all failed or late cancellations. For more than two failed or cancelled appointments you may be placed on same day only appointment basis.

DENTAL INSURANCE

If you have insurance coverage, our staff as a courtesy does their best to determine a proper ESTIMATE for you. Due to the many insurance companies and plans we cannot always predict the actual payments your insurance carrier will make. You are required to make payment of your full estimated responsibility upon services rendered. After payments are received from your insurance carrier, you may be required to make additional payments, have a credit issued to your account for future services or may be eligible for a refund. By signing this form, I hereby authorize and direct payment of dental benefits from my insurance company to New England Smile, LLC.

If you have Masshealth coverage, please be aware if you have a lapse in your coverage, or a procedure is denied, you are responsible for any out of pocket expenses that incur. You are responsible for understanding the benefits provided to you.

AUTHORIZATION AND RELEASE

I certify that the information provided is accurate and complete to the best of my knowledge. I authorize the dentist to release any information including the diagnosis and records of any treatment or examination rendered to me, or my child during the period of such dental care to third party payers and/or health practitioners.

INFORMATION REGARDING FILLINGS

Please be advised we no longer use silver (amalgam) fillings on primary (baby) teeth due to substantial improvement in composite/resin (white) filling materials. These new materials have been found to perform better than amalgam on primary teeth. We may still recommend, on occasion, silver (amalgam) fillings in certain cases for permanent (adult) molars or as a request of the parent.

Please be aware that some insurance plans pay differently on composite restorations and your co-payment may be higher. The balance is the patient’s responsibility.

Please contact your insurance if you have any concerns. If finances are a concern, we can submit a pre-treatment estimate with your insurance company for the treatment recommended. We will be happy to assist you with that request.

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the dental office of any changes in my medical status.

Parent/Guardian Signature

Date:

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I have read/received a copy of this office’s Notice of Privacy Practices.
You can find this office’s Notice of Privacy Practices within the HIPAA Privacy Statement located at the bottom of our main web page.

Patient Name

Parent/Guardian Signature

Date:

SOCIAL MEDIA CONSENT

We like to show off all the fun and great things that happen at New England Smile. Often times we do this on social media in the form of photographs or videos and include our patients and their families. Please let us know if we have your permission to post any photographs or videos that may include you or your child on various New England Smile social media sites. These may include (but are not limited to) Facebook, Google+, Twitter, and Instagram.

I consent to New England Smile social media usage

I do not consent to social media usage

Patient Name

Parent/Guardian Signature

Date:

ELECTRONIC COMMUNICATIONS ENCRYPTION WAIVER

When communicating via electronic media (e.g. email) HIPAA standards require us to utilize encryption technology for your privacy. To keep electronic communications private, we utilize third party encryption methods that typically require a password for viewing. If you prefer to avoid encrypting any emails that may contain private information and opt out of data encryption, please fill out the form below. By opting out of electronic encryption all electronic communications will be sent without password protection.

I wish to opt out of electronic encryption

Yes No

Patient Name

Parent/Guardian Signature

Date:

Frequent Headaches	Yes No
Heart Disorder	Yes No
Hepatitis	Yes No
Kidney Disease	Yes No
Liver Disease	Yes No
Rheumatic Fever	Yes No
Seizures	Yes No
Steroid Therapy	Yes No
Speech Problems	Yes No
Tuberculosis	Yes No
Thyroid Disease	Yes No
Other	Yes No
If Other, please explain

New Patient Registration - Adult

PATIENT INFORMATION

RESPONSIBLE PARTY

APPOINTMENT CONFIRMATIONS AND REMINDERS

INSURANCE INFORMATION

Primary Insurance

Secondary Insurance

MEDICAL HISTORY

DENTAL CONDITIONS

PERSONAL EVALUATION

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

SOCIAL MEDIA CONSENT

ELECTRONIC COMMUNICATIONS ENCRYPTION WAIVER

Fosamax	Yes No
Boniva	Yes No
Actonel	Yes No
Bisphosphonates	Yes No
Chemotherapy	Yes No

Abnormal Bleeding	Yes No
ADHD	Yes No
AIDS/HIV	Yes No
Allergies	Yes No
Anemia	Yes No
Asthma/Breathing disorders	Yes No
Cancer	Yes No
Cold Sores	Yes No
Diabetes	Yes No
Emotional/Psychological Disorder	Yes No
Epilepsy	Yes No
Fainting Spells	Yes No

Yes No	Are you apprehensive about dental/orthodontic treatment
Yes No	Have you had problems with previous dental/orthodontic treatment
Yes No	Have you ever had braces
Yes No	If you play sports do you wear a mouthguard
Yes No	Do you gag easily
Yes No	Do your gums bleed easily
Yes No	Are your teeth sensitive to hot or cold
Yes No	Do you clench or grind your teeth
Yes No	Do you have TMJ (Temporomandibular Jaw Disorder
Yes No	Do you use cigarettes, cigar, pipe or chewing tobacco