New Patient Form
Patient Information
Name:
Birthdate:
SS #:
Address:
City:   State:   Zip:
Select one:   Minor     Single     Married     Widow     Other
Home phone:
Email address:
Cell phone:
How did you first hear about Mohawk Dental?
Occupation / Employer:
If patient is a student, name of school and location?
Emergency contact:
Phone:
Primary Dental Insurance Information
Name of insured:
Date of birth of insured:
Insurance company:
SS # of insured:
Employer name:
ID #:   Group #:
Insurance address:
City:
State:   Zip:
Patient Dental Information
What is the reason for your visit?
Date of last dental care?
Date of last cleaning?
Date of last X-rays?
Are you currently in pain?
Yes     No
Has a doctor ever told you that you require antibiotics before dental treatment?
Yes     No
Have you ever had treatment for periodontal disease?
Yes     No
Do your gums bleed while brushing or flossing?
Yes     No
Do you wear dentures or partials?
Yes     No
Are you teeth sensitive to hot or cold liquids/foods?
Yes     No
Are your teeth sensitive to sweet or sour liquids/foods?
Yes     No
Have you ever experienced any of the following jaw problems?
Clicking
Yes     No
Pain (joint, ear, side of face)
Yes     No
Difficulty opening or closing
Yes     No
Difficulty chewing
Yes     No
Do you have any sores or lumps in or near your mouth?
Yes     No
Have you had any head, neck, or jaw injuries?
Yes     No
Do you have frequent headaches?
Yes     No
Do you clench or grind your teeth?
Yes     No
Do you bite your lips or cheeks frequently?
Yes     No
Do you ever catch food between teeth?
Yes     No
Have you ever had any difficult extractions in the past?
Yes     No
Have you ever had any prolonged bleeding following extractions?
Yes     No
Have you had any orthodontic work?
Yes     No
Have you ever had instruction on the correct method of brushing your teeth?
Yes     No
Have you ever had instruction on the care of your gums?
Yes     No
If you could change anything about your smile, what would you change?
Patient Medical Information
Name of primary care physician:
City/town:
Have you ever been hospitalized for any surgical operation or serious illness? If yes, please explain:
 
Do you have or have you had any of the following?
Anaphylaxis
Yes   No
Anemia
Yes   No
Angina
Yes   No
Arthritis
Yes   No
Asthma
Yes   No
Cancer
Yes   No
Chest Pain
Yes   No
Cold Sores / Fever Blisters
Yes   No
Congenital Heart Problems
Yes   No
Cortisone Treatments
Yes   No
Cough (Persistent)
Yes   No
Diabetes
Yes   No
Easily Winded
Yes   No
Eating Disorders
Yes   No
Emphysema
Yes   No
Fainting
Yes   No
Frequently Tired
Yes   No
Glaucoma
Yes   No
Hay Fever
Yes   No
Heart Attack
Yes   No
Heart Disease
Yes   No
Heart Murmur
Yes   No
Heart Surgery
Yes   No
Hemophilia
Yes   No
Hepatitis
Yes   No
Herpes
Yes   No
High Blood Pressure
Yes   No
HIV or AIDS
Yes   No
Hyperthyroidism
Yes   No
Hypoglycemia
Yes   No
Hypothyroidism
Yes   No
Kidney Disease
Yes   No
Leukemia
Yes   No
Liver Disease
Yes   No
Low Blood Pressure
Yes   No
Mitral Valve Prolapse
Yes   No
Nervous Problems
Yes   No
Osteoporosis
Yes   No
Pacemaker
Yes   No
Psychiatric Treatment
Yes   No
Radiation Therapy
Yes   No
Recent Weight Loss / Gain
Yes   No
Respiratory Problems
Yes   No
Rheumatic Fever
Yes   No
Rheumatism
Yes   No
Seasonal Allergies
Yes   No
Seizures / Epilepsy
Yes   No
STD
Yes   No
Shingles
Yes   No
Stomach Problems / Ulcers
Yes   No
Stroke
Yes   No
Swollen Ankles or Feet
Yes   No
Tonsillitis
Yes   No
Tuberculosis
Yes   No
Tumors
Yes   No  
 
Do you have any disease, condition or problem not listed above that you think we should know about?
Are you taking any medication(s) including non-prescription medicine? If yes, what medication(s)?

Are you allergic to or have you had any reactions to the following?
Local Anesthetics
Yes   No
Iodine
Yes   No
Penicillin
Yes   No
Aspirin
Yes   No
Codeine
Yes   No
Metals
Yes   No
Sulfa drugs
Yes   No
Latex
Yes   No
Barbituates
Yes   No
Sedatives
Yes   No
Other allergies?
 
 
Have you ever taken bisphosphonates?
Yes     No
Do you or have you used tobacco?
Yes     No
Do you or have you used controlled substances?
Yes     No
Do you use alcohol?
Yes     No
Are you wearing contact lenses?
Yes     No

Women only:
Are you pregnant or think you may be pregnant?
Yes     No
Are you nursing?
Yes     No
Are you taking birth control pills?
Yes     No

Our Practice Policies
If there is any change in my medical status, I will inform my provider immediately. I authorize Mohawk Dental to perform any necessary services needed during diagnosis and treatment. I understand that providing incorrect information can be dangerous to my health. I authorize release of my treatment records, as well as my child's, to third party payers and health practitioners involved in my care.

By providing my electronic signature, I consent to do business electronically. I have the right to withdraw consent at any time. If I would like a paper copy of a communication previously sent electronically, I may request a copy from the Practice at any time.

I understand that I am required to provide 48 hours notice of any appointment change or cancelation, and that a $50 fee may be charged for an appointment changed, canceled, or missed without providing 48 hours notice. Appointments 90 minutes or longer have a higher cancellation fee of $50 per 30 minutes of appointment length.

If I have dental insurance, Mohawk Dental will submit my insurance claim as a courtesy and will accept assignment of benefits on my behalf. Regardless of what Mohawk Dental may calculate my insurance company to pay, it is only an estimate. If I am unable to pay my entire estimated co-pay on the date of service, I will complete an Installation Payment Agreement. I understand that my insurance may pay less than the estimated fee or nothing at all. I am responsible for payment of all services rendered to me and my dependents.

I understand that balances over 30 days old, without a signed Installment Payment Agreement, are considered delinquent, and will incur 6% interest until paid. I agree to be responsible for all attorney fees, collection agency fees, interest, and other documented expenses incurred during the collection of my account.
Notice of Privacy Practices Acknowledgement
I understand that, under the Health Insurance Portability & Accountability Act of 1976 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
  • Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
  • Obtain payment from third-party payers.
  • Conduct normal healthcare operations such as quality assessments and physician certifications.

I have read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above 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 and disclosed to carry out treatment and payment of health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

Printed name of person filling out this form:
I have read and understand these policies and agree to abide by their terms. All of my questions at this time have been answered. I understand these policies may be amended by the practice at any time. I consent to do business electonically and to receive emails, text messages, and automated phone calls from the practice.

Please sign below with your mouse or finger.