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Web Site

Patient Information

Patient First Name *

Patient Last Name *

Email Address *

Date of Birth *

Social Security Number

Drivers License Number

Gender *

Marital Status *

Street Address *

Street Address 2

City *

State *

Zip Code *

Home Phone Number *

Cell Phone Number

Work Phone Number

How did you hear about our office?

Friend/Family Member

Marketing

Website

Insurance Company

Other

Please Specify

Is another member of your family a patient here? *

Yes No

Payment Information

Person Responsible for Payment *

Self

Parent/Guardian

Other

Do you have Dental Insurance? *

Yes No

INSURANCE POLICY: Our office submits to insurance companies as a courtesy to our patients. Any balances not paid by the insurance company are the patient's responsibility. All patient estimates are due at the time of service. If you do not have insurance, full payment is expected at the time of service. All past-due accounts with balances over 30 days old are subject to a service charge of $5 per month late. If it becomes necessary to seek the assistance of an attorney, court costs and attorney fees will be added to your bill to the extent permitted by law. To avoid a missed appointment fee of $25, please give us at least 24 hours advance cancellation notice to reschedule. A broken not only hurts you and the doctor, but permits another patient from being see.

By checking this box, I agree to the Insurance Policy as Stated above. *

I Agree

Signature of Responsible Party *

Relationship *

Date *

Medical History

Patient's Name *

Have you been under the care of a medical doctor in the last two years?

Yes

Emergency Contact Name *

Emergency Contact Phone *

Emergency Contact Relationship

Emergency Contact Address

Emergency Contact Address 2

Emergency Contact City

Emergency State

Emergency Zip

Primary Care Physician

Physician Address

Physician Address 2

Physician City

Physician State

Physician Zip

Previous Dentist Name

Date of Last Dental Visit

Date of Last Dental X-Rays

Are you experiencing any dental problems at this time? *

Yes

Do you like your smile? *

Yes

Do your gums bleed at any time? *

Yes

Do you have any problems with dry mouth? *

Yes

Do you ever feel nervous about having dental treatment? *

Yes

Are you allergic to any medications (ie. Penicillin, Aspirin, Codeine) *

Yes

Do you smoke? *

Yes

Check any of the following you have had or currently have: *

Heart Failure

Heart Disease or Attack

Angina Pectoris (chest pain)

Heart Pacemaker

Heart Surgery

Tuberculosis

Asthma

Rheumatic Fever

Scarlet Fever

Artificial Joints

Heart Murmur/Mitral Valve

Stroke

Kidney Trouble

Hepatitis (A, B or C)

Liver Disease

Fainting or Dizzy Spells

Hay Fever

Allergies or Hives

Diabetes

Thyroid Disease

X-Ray or Cobalt Treatment

Chemotherapy

Arthritis

Glaucoma

TMJ/TMD

Cold Sores/Fever Blisters

Hemophilia

Venereal Disease

HIV Positive

Epilepsy or Seizures

Jaundice

Ulcers

Psychiatric Treatment

Sickle Cell Anemia

Bruise Easily

Emphysema

Anemia

Shortness of Breath

High Blood Pressure

None of the above

Are you taking any medications? *

Yes No

APPOINTMENT POLICY: Out of respect for our patients' busy schedules, our office reserves a specific time for your dental appointment and makes every effort to run on time for these appointments. In return, we ask that you: - Please call ahead if you are unable to keep your appointment. This allows the office to schedule another appointment in your vacated time slot. If you fail to call ahead and/or do not show up for your appointment time, we reserve the right to charge a $25.00 missed appointment fee. If you have dental insurance, you will be personally responsible for this fee as we cannot submit a missed appointment fee to your dental insurance company. - Please arrive on time for your dental appointment. If you are running late, the courtesy of a telephone call to let us know is appreciated. This allows the doctors and hygienists to see other patients while we await your arrival and allows us to adjust your appointment time. We understand that emergencies occasionally arise that prevent you from adhering to this Appointment Policy. Implementation of this policy is designed to help us better serve our patients and eliminate continued disrespectful behavior rather than 'punish' patients in the event of an emergency. My name below denotes my understanding of and agreement with this Appointment Policy.

By Checking this box, you agree to the Appointment Policy as stated above. *

I agree

Name *

Relationship *

Date *

FINANCIAL POLICY: Thank you for choosing South County Smiles! Our primary mission is to deliver the best and most comprehensive dental care available. An important part of the mission is making the cost of optimal care as easy and manageable for our patients by offering serval payment options. Patient payment is due at the time of service. No billing is done from our office. For your convenience, we have the following 4 payment options. 1. Cash/Check - We offer a 5% discount on treatment for patients who pay for their treatment with cash of check prior to completion of care on treatment plans in excess of $500. 2. Care Credit - Care Credit allows you to pay for your treatment over time. It offers Interest Free monthly payments options in 6 or 12 month options when payments are made on time. It does not have annual fees or prepayment penalties. 3. Visa, Mastercard, Discover or American Express - Accepted at the time services are rendered. 4. Credit Card on File - This is a simple way to make your payments hassle-free. Please ask for a form and the credit card of your choice will be kept on file. Storing of your credit card information authorizes us to use your card for any outstanding balances on your account. Upon charging your card, a detailed invoice informing you of the amount charged, date of transaction, and associated services will be mailed to you.

By Checking this box, I agree to the Financial Policy as stated above. *

I agree.

Signature *

Relationship *

Date *

New Patient Form – Fill Out Online

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