Patient Forms at Middlecoff Dental Group

Patient Name

First Last

Preferred Name

Address

Street Address City State Zip

Gender

Male

Female

Birth Date

Email Address

Home Phone

Cell Phone

Work Phone

Would you like text reminders?

Yes

May we contact you at work?

Yes

How did you hear about our office?

Emergency Contact Name

First Last

Emergency Contact Phone

Dental HIstory

On a scale of 1-10, with 10 being excellent health, where would you rate your current oral health?

On a scale of 1-10, where would you like your oral health to rank?

Do you have a specific dental problem?

If yes, please describe:

Date of last dental visit

Have you ever had a less than positive experience at the dentist?

Yes

If so, would you mind if the doctor asks you about that negative experience?

Yes

Do your gums bleed?

Yes

Do you use tobacco?

Yes

Are you happy with your smile?

Yes

Are you interested in whiter teeth?

Yes

Medical History

Are you under a physician’s care now? If yes, describe reason

List all prescribed medications, over the counter medications and Vitamins/herbal supplements.

Are you taking a blood thinner such as Warfarin, Coumadin, Pradaxa, Xarelto, Plavix, Brilinta, Eliquis or Clopidogrel?

Yes

Have you ever taken or are you currently taking bisphosphonate drugs for osteoporosis such as Zometa, Reclast, Aredia, Fosomax, Actonel, Boniva or Didronel?

Yes

Have you ever taken or are you currently taking biologic type medication such as Humira, Enbrel, Prolia, Xgeva, Remicade or Avastin?

Yes

Have you ever received head/neck radiations? (NOT dental radiation)

Yes

Women, check which applies.

Pregnant/trying to get pregnant

Nursing

Taking oral contraceptives

Are you allergic to:

Aspirin

Acrylic

Metal

Milk

Latex

Sulfa

Penicillin

Codeine

None

Please list any Other allergies

Have you ever had any other serious illness not listed here or an injury to the head or neck?

Preferred Pharmacy

To the best of my knowledge, all the preceding answers are correct. If I have any changes in my health status or if my medicines change, I shall inform the dentist and staff at the next appointment without fail. I agree with the information listed above.

Signature

First Last

Date

I have been provided with a copy of Middlecoff Dental Group’s Privacy Policy.

Patient or Responsible Party

Social Security Number

Date

Cancellation and missed Appointment Policy

We always provide courtesy reminder calls, text or e-mails to remind you of you reserved appointment time. We ask that you confirm your appointment either by a return phone call, text or email. If we do not get a confirmation from you regarding your appointment, we reserve the right to remove your appointment from our schedule if that time is needed for another patient. If you just reschedule or cancel your appointment, we require 24 hours notice to avoid a broken appointment fee. The fee for a 1st broken appointment is $100, 2nd $125 and 3rd is $150. After 3 broken appointments we will only be able to see you on a walk-in basis if our schedule allows.

I agree with the information listed above.

Signature

First Last

Dental Insurance Information

Subscriber Name

Social Security Number

Insurance Company Name

ID#

Group#

Insurance filing and Financial Responsibility

As a service to our patients with insurance, Middlecoff Dental Group agrees to accept an estimated co-payment at the time service is rendered and bill insurance for the balance.

Even with our best efforts, we can only estimate what insurance will pay. We are never given a guarantee of coverage or benefits from your insurance carrier, and situations may arise when insurance will deny a claim or a portion of a claim when we submit it for payment. We will always restore teeth with tooth colored composite fillings since we feel that this type of restoration is far superior to silver amalgam fillings. Many insurance companies only pay for amalgam fillings. If this is the case, you will be responsible for the difference in cost between composite and amalgam.

Insurance is a contract between you and your carrier and if you have concerns, we strongly suggest that you contact your carrier prior to your visit.

IF insurance pays less than estimated or not at all, I agree to pay any amount not paid by my insurance to Middlecoff Dental Group. I authorize the release of any information necessary to process my claims. The information I have given is accurate and true to the best of my knowledge.

Patient or Responsible Party

Date

Patient Forms in Somerville, TN

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Dental HIstory

Medical History

Dental Insurance Information

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Middlecoff Dental Group