Patient Forms

We are excited you have chosen to become a patient! We need to get to know you a little more. Please complete our new patient form. You can either download the form (Adobe PDF format), complete and bring with you to your appointment or complete the online form below and submit digitally to us.

Download Patient Forms

PATIENT INFORMATION

Today's Date *

Patient Last Name *

First Name *

Middle Name *

Patient Address

Street Address

City

State

Zip

Email *

Sex *

Age *

Date of Birth *

Patient Employer/School

Occupation

Employer/School Address

Employer/School Phone

Spouse's Name

Date of Birth

SS#

Spouse's Employer

Home Phone

Work Phone

Cell Phone

Spouse's Work Phone

Best time and place to reach you

EMERGENCY CONTACT

Name *

Relationship *

Home Phone *

Work Phone *

DENTAL INSURANCE

Who is responsible for this account? *

Relationship to Patient *

Insurance Company *

Group Number *

Is patient covered by additional insurance? *

Yes
No
Third Choice

Subscriber's Name

Date of Birth

SS#

Relationship to Patient

Insurance Company *

Group Number *

ASSIGNMENT & RELEASE

I certify that I, and/or my dependent(s), have insurance coverage with

Insurance Company *

and assign directly to:

Doctor's Name *

all insurance benefits, if any, otherwise payable to me for services rendered. 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.

The above-named dentist may use my health care information and may disclose such information to the above-named Insurance Company(ees) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

Signature of Patient, Parent, Guardian or Personal Representative *

Clear Name of Patient, Parent, Guardian or Personal Representative

Date / Time *

Relationship to Patient *

DENTAL & MEDICAL HISTORY

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions pertaining both your dental and medical history.

Reason for today's visit *

Former Dentist *

City/State *

Date of last dental visit

Date of last dental X-rays

PLEASE MARK "YES" OR "NO" TO INDICATE IF YOU HAVE HAD ANY OF THE FOLLOWING:

Sensitivity when biting *

Sores or growths in your mouth *

How often do you floss? *

How often do you brush? *

Women, are you:

Pregnant/trying
Nursing
Taking oral contraceptives

If other, please specify:

Are you taking any pills, medication or drugs? *

Do you take, or have taken, Phen-Fen or Redux? *

Have you ever taken Fosamax, Boniva, Actonel or any other medication containing bisphosphonates? *

DO YOU HAVE, OR HAVE HAD, ANY OF THE FOLLOWING?

Yellow Jaundice *

Have you ever had any serious illness not listed above? *

If yes:

For INFANT patients ONLY...

How much does your baby currently weigh?

Did you refuse a vitamin K shot while at the hospital?

Is baby breastfeeding?

Are you working with a lactation consultant? If so, who?

Were you referred here for a tongue tie and/or lip tie release? If so, who referred you?

Comments

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 (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

Signature of Patient, Parent, Guardian or Personal Representative *

Date / Time *

NOTICE OF PRIVACY PRACTICE ACKNOWLEDGEMENT & PATIENT CONSENT FORM

I understand, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health/dental information. I understand this information can and will be used to: -Conduct, plan and direct my treatment and follow up among multiple healthcare providers who may be involved in my treatment directly and/or indirectly. -Conduct normal healthcare operations, such as physician certifications and assessments. -Obtain payment from third party payers, such as insurance companies. -Confirm and leave messages at phone numbers provided to this office. I have been informed of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this office has the right to change its Notice of Privacy Practices from time to time and that I may contact this office at anytime to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or dental care operations. I also understand you are not required to agree to my restrictions, but if you do agree then you are bound to abide by such restrictions.

Patient Name *

Relationship to Patient *

Additional family members given access

Signature *

Date *

Phone

We can't wait to see you!

Office Hours:

Monday-Wednesday 8 a.m. to 1 p.m. and 2 p.m. to 5 p.m.

Thursday 8 a.m. to 3 p.m.

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405 324 0200

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reeddentalcare@gmail.com

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Patient Forms

PATIENT INFORMATION

EMERGENCY CONTACT

DENTAL INSURANCE

DENTAL & MEDICAL HISTORY

For INFANT patients ONLY...

NOTICE OF PRIVACY PRACTICE ACKNOWLEDGEMENT & PATIENT CONSENT FORM

We can't wait to see you!

405 324 0200

reeddentalcare@gmail.com

420 S Mustang Rd Yukon, OK 73099