New Patient Forms

Patient and Insurance Information

First Name *

Middle Name *

Last Name *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaAustraliaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCabo VerdeCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGuernseyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauNorth MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSaint HelenaSaint Pierre & MiquelonSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUS Minor Outlying IslandsUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabwe

Preferred Phone Number *

Is this a mobile number? *YesNo

Who should we thank for referring you

Email Address *

Date of Birth *

MonthSelect month123456789101112

DaySelect day12345678910111213141516171819202122232425262728293031

YearSelect Year212421232122212121202119211821172116211521142113211221112110210921082107210621052104210321022101210020992098209720962095209420932092209120902089208820872086208520842083208220812080207920782077207620752074207320722071207020692068206720662065206420632062206120602059205820572056205520542053205220512050204920482047204620452044204320422041204020392038203720362035203420332032203120302029202820272026202520242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924

Sex *MaleFemaleUnspecified

Emergency Contact *

Emergency Contact Phone # *

Primary Language *EnglishSpanishOther

Other language *

Primary Dental Insurance

Is subscriber the same as patient?YesNo

Subscriber Information

First Name

Middle Name

Last Name

Employer Name

Insurance Company

Insurance Phone Number

Subscriber ID/Policy Number

Group/Contract Number

Subscriber Date of Birth

MonthSelect month123456789101112

DaySelect day12345678910111213141516171819202122232425262728293031

YearSelect Year212421232122212121202119211821172116211521142113211221112110210921082107210621052104210321022101210020992098209720962095209420932092209120902089208820872086208520842083208220812080207920782077207620752074207320722071207020692068206720662065206420632062206120602059205820572056205520542053205220512050204920482047204620452044204320422041204020392038203720362035203420332032203120302029202820272026202520242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924

Subscriber SSN

Patient Relationship to SubscriberChildDisabled DependentHusbandSelfWifeOther Dependent

Medical Health Insurance (not Medicare or HMO)

Is subscriber the same as patient?YesNo

Subscriber Information

Employer Name

Insurance Company

Insurance Phone Number

Subscriber ID/Policy Number

Group/Contract Number

Subscriber Date of Birth

MonthSelect month123456789101112

DaySelect day12345678910111213141516171819202122232425262728293031

YearSelect Year212421232122212121202119211821172116211521142113211221112110210921082107210621052104210321022101210020992098209720962095209420932092209120902089208820872086208520842083208220812080207920782077207620752074207320722071207020692068206720662065206420632062206120602059205820572056205520542053205220512050204920482047204620452044204320422041204020392038203720362035203420332032203120302029202820272026202520242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924

Subscriber SSN

Patient Relationship to SubscriberChildDisabled DependentHusbandSelfWifeOther Dependent

Health History

Reason for Visit *Broken ToothCheck-upCosmeticDenturesTooth PainOther

Other Reason

Height (in feet and inches) *

Weight *

Are you under the care of a primary physician? *YesNo

Primary Physician's Name

Physician's Phone Number

Date of Last Physical *I don't know the exact dateLast 6 months6 months - 1 year1-3 yearsGreater than 4 yearsNeverOther

Other

Are you taking, or have you taken any steroid/cortisone therapy in the last 2 years? *YesNo

Have you ever been hospitalized? *YesNo

Are you taking or have you taken Oral Bisphosphonates (e.g., FOSAMAX, BONIVA) or IV Bisphosphonates, (e.g., ZOMETA, AREDIA)? *YesNo

How Long?

Do you require antibiotics prior to dental procedures? *YesNo

Are you allergic or have you had an adverse reaction to any of the following? *No/NoneAmoxicillinAspirinCodeineEpinephrineLatexMetalsNovocainPenicillinSulfaTetracyclineOther

Other

List any medications you are taking including non-prescription drugs and herbals/vitamins *

Check any conditions that apply to you *NoneAlcoholismAllergies or HivesAnemiaArthritisArtificial Joint/PinsAspirin TherapyAsthmaBlood ThinnersBlood TransfusionBreathing ProblemsCancerChemotherapyCoumadin TherapyDementiaDiabetesDrug AddictionEpilepsyExcessive BleedingFainting/DizzinessHearing ImpairmentHeart MurmurHeart SurgeryHeart TroubleHepatitisHigh Blood PressureHIVKidney DiseaseLiver DiseaseLow Blood PressureLung Disease/COPDLupusMitral Valve ProlapseMobility ImpairmentNON-DENTAL ImplantsOrgan TransplantsPacemakerPsychiatric CareRadiation TherapyRadiosurgeryRheumatic FeverSeizuresSexually Transmitted DiseaseSinus ProblemsStomach ProblemsStrokeThyroid DiseaseTuberculosis (TB)UlcersVisual ImpairmentOther Disease/Illness

Artificial Joint/Pins: Type

Artificial Joint/Pins: Age

Cancer: Type

Diabetes: Type

Date of Heart Surgery

Heart Trouble: Type

NON-DENTAL Implants: Type

Organ Transplants: Type

Other Disease/Illness

Dental History

Date of Last Dental Visit *I don't know exact dateLast 6 months6 months - 1 year1-3 yearsGreater than 4 yearsNeverOther

Other

Date of Last Dental X-ray *I don't know exact dateLast 6 months6 months - 1 year1-3 yearsGreater than 4 yearsNeverOther

Other

Oral Health

Have you ever been treated for periodontal (gum) disease? *YesNo

Have you ever had Novocain or another local anesthetic? *YesNo

How happy are you with your smile (1-10)? *

Are you currently wearing Dentures? *YesNo

Age of denturesLess Than 6 Months6 months-3 yearsGreater than 4 years

Please check any conditions that apply to you below:Pain in Jaw (TMJ)Teeth Grinding/ClenchingUse Tobacco ProductsMouth SoresSensitive TeethBroken/Loose TeethDifficulty Chewing/SwallowingSwollen/Bleeding Gums

Woman Patients Only

Are you currently pregnant? *YesNo

Are you Nursing? *YesNo

Estimated Delivery Date

Are you taking any birth control prescriptions?YesNo**NOTE Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician/gynecologist for assistance regarding additional methods of birth control.

Patient Signatures

I certify that I have read and understand the above questions and acknowledge that questions have been answered to the best of my knowledge. I hereby give my consent to the dentist to perform an examination and diagnose my condition. I also give my consent for any preventive or basic restorative procedures which may be necessary. I understand that this consent will remain in effect until treatment is terminated either by me or the dentist. *

Patient Signature Date *

Release of Information to Insurers and Assignment of Benefits (must be signed by all patients with insurance and those who expect to obtain insurance)

To the extent permitted by law, I consent to my practices (or their designees) use and disclosure of my Protected Health Information to carry out payment activities in connection with my insurance claim. This information will be used exclusively for the purpose of evaluating and administering claims for benefits. I further authorize and direct payment to my practice of the dental benefits otherwise payable to me. *(If patient is a minor or disabled the Parent, Guardian or Attorney-in-Fact must sign and complete the Responsible Party section.)

Patient Signature Date *

Authorization for Release of Health Records to External Parties (optional)

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I authorize the disclosure of information from my treatment records to:

Relationship to the Patient:

I give authorization to disclose the following information:all treatment informationinformation specifically related to these treatment dates

Starting Date

End Date

Consent to obtain patient medication history (optional)

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To the extent permitted by applicable law, I authorize this dental practice (or their designees) to collect information about my prescription history from my pharmacy and insurers (as applicable) and give my pharmacy and insurers permission to disclose such information. This includes prescription information related to medicines to treat AIDS/ HIV and medicines used to treat mental health issues.

Date

Payment, Insurance, and Financial Arrangement Policies (signed by ALL New Patients)

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By signing below, I acknowledge that I received the Financial Policies form and agree to abide by such policies. *(If patient is a minor or disabled the Parent, Guardian or Attorney-in-Fact must sign and complete the Responsible Party section.)

Date *

Notice of Privacy Practices (must be signed by ALL new patients)

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By signing below, I acknowledge that I have read the Notice of Privacy Practices, as mandated by the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"). *(If patient is a minor or disabled the Parent, Guardian or Attorney-in-Fact must sign and complete the Responsible Party section.)

Date

Submit Form

My Time Dental Centers is committed to providing exceptional service and treatment that addresses both your short- and long-term needs.

1. A Clear, Written Estimate on your Cost of Treatment

Dr. Schmelter will provide you with a comprehensive treatment plan based on your overall health. You will also receive a clear, detailed estimate of the cost of your plan, including your estimated insurance benefits. If you have questions regarding your insurance coverage, please contact your insurance company.

2. Financial Agreement

a) I agree to pay a $35.00 Fee on all returned or cancelled checks.

b) I understand there is a NO SHOW/CANCELLATION FEE for all appointments. There may be a fee of $50 and will be changed per hour of time scheduled. Please give 48-hour notice if you are unable to keep your appointment.

3. Payment Policy

a) Full payment of what you owe (called the Patient Financial Responsibility amount, as noted in your Treatment Acceptance and Payment Arrangement Form), is due when services are rendered. We accept cash, personal checks, Visa®, Master Card®, American Express®, Discover®, assigned insurance benefits, and select third-party financing programs.

b) 10% Discount for our uninsured cash/check paying patients, cannot be combined with any courtesy discounts.

4. Dental Insurance
If you have dental insurance, your insurance claim will be processed as follows:

• In Network: If your dentist is a participating provider in your insurance network, you will be billed according to the terms of your dentist's agreement with your insurer.
• Out of Network: If your dentist is not participating or in-network provider with your insurance plan, we will honor your carrier's in-network fee structure. If your insurance carrier will not accept your assignment of benefits to your dentist, you are responsible for the estimated insurance benefit.

Insurance Discounts: Insurance companies often negotiate discounts for services provided to their plan members. If you exceed your annual benefit limit the insurer's discounted rate may apply to additional services as a benefit to you.

5. Third-Party Financing
My Time Dental Centers accepts payment from non-affiliated, third party finance companies. Credit decisions are the responsibility of these third-party finance companies. You may choose to pay all or a portion of your treatment using approved third-party financing products.

6. Patient Communication
We'd like to keep in touch regarding your upcoming appointments, treatment plan, and treatment status. By providing your email address, phone number, and mailing address, you are giving My Time Dental Centers permission to contact you through one or all of these communication methods. Note that email and text messaging is not secure and there is a risk that they could be read by a third party. By sharing your email or mobile number with us you are acknowledging that you are aware of this risk and agree to receive this type of communication.