Name *

First Name Last Name

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone *

Area Code Phone Number

Work Phone

Area Code Phone Number

Email *

example@example.com

Date of Birth *

Date

Sex *

Male Female

Marital Status

Married Single Divorced Other

Responsible Party

Name

First Name Last Name

Phone

Area Code Phone Number

Relation

Email *

example@example.com

How did you hear about our office? *

Google/Reviews Drive by Friend / Family Other

Dental Insurance

Primary Insurance Carrier

Phone Number

Area Code Phone Number

Subscriber

Check if self

Name

First Name Last Name

Date of Birth

Date

SSN

Employer, if group plan

Secondary Insurance Carrier

Phone Number

Area Code Phone Number

Subscriber

Check if self

Name

First Name Last Name

Date of Birth

Date

SSN

Employer, if group plan

* We accept all dental insurances, with the understanding that any portion not covered by the patient's insurance is to be the patient/responsible party.

In Case of Emergency

Name

First Name Last Name

Phone

Area Code Phone Number

Current Physician

Phone

Last Checkup

Currently under the care of a physician?

Yes No

If yes, for

How would you rate your overall health?

Excellent Good Fair Poor

Do you smoke or use tobacco?

Yes No

Do you have any allergies? Please list

Current Medications: include prescriptions, over-the-counter, and supplements.

Please include medication name, dose, and frequency.

Have you ever had any of the following diseases or medical conditions?

If you checked "Other," please describe.

Are you currently pregnant?

Yes No

If yes, when is the due dat?

Date

Are you currently breastfeeding?

Yes No

Previous Dentist

Phone Number

Area Code Phone Number

Last Checkup

Date

Have you ever had to take pre-medication for your dental appointments?

Yes No

What brings you to our office today?

Are you currently in pain?

Yes No

How would you rate your oral health?

Excellent Good Fair Poor

How often do you brush?

Which type of toothbrush do you use?

Manual Electric

How often do you floss?

Do your gums ever bleed?

Yes No

Do you like your smile?

Yes No

Have you ever experienced any of these symptoms?

Here are some things we would like to learn about you and discuss during your first visit. These are issues you may have never thought about. Please mark all the items that you have or have had.

Joint Dysfunction

Are you aware of any joint sounds, past or present?

Yes No

Do you ever have pain or soreness in or around your ears?

Yes No

Do you wake up with sore or tired jaws?

Yes No

Do you ever have difficulty opening widely?

Yes No

Do you avoid eating certain foods because of pain or discomfort?

Yes No

Headaches

Do you get headaches?

Yes No

If so, how often?

Have you been evaluated or treated for your headaches?

Yes No

Has there been a change in your headache pattern?

Yes No

Does anything trigger your headaches?

Yes No

On a scale from 1 to 10, 1 being no pain and 10 being crippling pain, what is the range of your headaches?

How have headaches affected your life?

Sleep

Do you snore?

Yes No

Do you have high blood pressure?

Yes No

Has anyone reported that you choke or gasp for air while sleeping?

Yes No

Are you excessively tired during the day?

Yes No

Your Smile

Do you want whiter teeth?

Yes No

Are your teeth as straight as you want them?

Yes No

Would you like to change your silver fillings to tooth coloured fillings?

Yes No

Are you interested in veneers?

Yes No

Is there anything else about your smile that is bothering you?

Yes No

If so, please explain.

Notes about above

We have the ability to look at your mouth from 3 different perspectives. What combination of these would you like us to use for you?

As a general dentist As a cosmetic dentist As a functional dentist Check all that apply

What quality of dentistry do you want us to recommend?

Just patch it Average Ideal/the best

If you need treatment, at what point should we address it?

When my tooth hurts or breaks When something is worsening When something isn’t ideal

How healthy do you want us to get your mouth?

Out of pain Average The best it can be

What do you already know about our office and what are your expectations?

What caused you to leave your last dental office?

Tell us about your good dental experiences.

And the bad ones.

What would it take for you to trust us to be your dentist?

Has anxiety or fear been an issue for you in a dental office?

Yes No

Is there any additional information you would like us to know?

Recommended Oral Cancer Exam

Our practice continually strives to provide important enhancements in oral health for our patient. We are concerned about oral cancer and look for it in all at risk patients.

Oral cancer is a silent killer and the maximum survival is five years. One person dies every hour from oral cancer in the United States.

Late detection of oral cancer is the primary reason that mortality rates are so dismal. As with most other cancers, age is the primary risk factor for oral cancer. Though tobacco use is a major predisposing risk factor, 25% of oral cancer victims have no lifestyle risk factors.

Increased risk:

18-39 years of age combined with any of the following Tobacco use
Chronic alcohol consumption
Oral HPV infection

Highest Risk:

Patients age 65 and older with lifestyle risk factors.
Patients with history of Oral Cancer

25% of oral cancer occurs in people who don’t smoke and have no other risk factors. Early detection is a key to successful treatment.

We find that using Velscope plus along with a visual oral cancer examination improves our ability to identify suspicious areas that may have been missed during the conventional examination. Early detection of precancerous tissue can minimize or eliminate the potentially disfiguring effects or oral cancer and possibly save your life. The Velscope is a painless exam that gives us a better chance to find any oral abnormalities you may have at an early stage.

Dental insurance might not cover the Velscope exam. However, this office is happy to verify with your coverage for you. The fee for this enhanced examination is $48.00.

Yes, I authorize Dr. Deldar to perform the Velscope exam. I accept financial responsibility for this enhanced examination. *

Yes, I authorize Dr. Deldar to perform the Velscope exam. I accept financial responsibility for this enhanced examination. No, I would prefer not to have the Velscope exam at this time.

Financial Agreement

I/We understand that I am /we are responsible for all charges incurred within fifteen (15) days of request for payment by Deldar Dental (Dr. Mike and Dr. Sara Deldar).

In consideration of the services to be provided to the customer/patient, I/we hereby guarantee payment in full of the customer's account in accordance with the financial arrangements made at the time of service/purchase or, if no such arrangemtns are made, in event of default in payment, reasonable collection agency fees up to thirty-five (35%) percent of the delinquent balance and reasonable attorney fees, shall be added to the amount due on the account, plus any applicable court costs.

By providing my phone number, I give prior express consent to receive calls and text messages from the creditor or its third party debt collector at that number, including calls and messages made by using an auto-dialer or pre-recorded message.

Deldar Dental accepts cash, check, Visa, MasterCard, and Discover; Deldar Dental also works with outside financing companies to help you to afford your treatment upon our approval.

*

I accept the terms listed above. All information given in this form is accurate and to the best of my knowledge.

Patient Signature or responsible Party (if under 18, parent or guardian

Clear

Today's Date *

Date

New Patient Form

Patient Information

Dental Insurance

Medical History

Women:

Dental Background

Financial Agreement