New Patient – Bay Wellesley Dental

NEW PATIENT

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Address

Address Line 1

City

State / Province / Region

Postal Code

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Cell Phone

Home Phone

Occupation

Work Phone

I consent to receive appointment notifications and newsletters

I consent to receive appointment notifications and newsletters

Notes (specific time of the day or any consideration):

Emergency Contact

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Full Name

Relationship

Emergency Cell Phone

Emergency Home Phone

Notes (specific contact instructions or preferences)

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Family Physician

Full Name

Office Phone

Specialist For

Full Name

Office Phone

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How can we help you?

Comprehensive Exam
Dental Hygiene/Cleaning
Pain Relief/ Emergency
Other

How did you hear about us ?

Referral:

Primary Insurance

Insured Name

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First Name

Last Name

Date of Birth

Insured Employer

Insurance Company

Plan or Group

Certificate/Member ID

Secondary Insurance (if available)

Insured Name

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First Name

Last Name

Date of Birth

Insured Employer

Insurance Company

Plan or Group

Certificate/Member ID

Relationship to Insured

Insured Cell Phone

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When was your last Dental visit?

When was your last Medical check‐up?

Do you have tendency to bruise easily or bleed for a prolonged period of time?

Have you ever had or are receiving Chemo or Radiation Therapy?

Any ill effects from it?

Do you require any Medications or Antibiotics before Dental Treatment? *

Do you take cannabis/cannabis products?

Are you currently being treated for any Medical conditions? Are you currently being required to self‐isolate?

Are you taking any Medications (including blood thinners such as Aspirin, Coumadin/Warfarin, Heparin, Eliquis, etc.) or Non‐Prescription Drugs?

Has your physician ever told you to take antibiotics prior to dental procedures?

Have you ever taken or been given bisphosphonate medication or any of its family?

Have you ever taken cortisone or steroids?

Has there been any changes in your general health recently? Have you gained or lost excessive weight?

Have you ever been seriously ill, hospitalized or had any major surgery?

Have you ever had a peculiar or adverse reaction to any Medication, Injection or Anesthesia?

Do you have allergies or sensitivities to any Food or Material (including Latex)?

Have you ever had freezing (local anesthetic) in your mouth?

Have you ever had a complete dental examination with a full series of dental x-rays within the past 3 years?

Have you ever had a bad experience at the dentist?

Reason for leaving previous dentist

Is there anything else you think we should know regarding your medical history?

To the best of your knowledge, are you in good health?

Do you have or ever had the following

Chest Pain/Angina
Shortness of Breath
Nausea
Fainted

Do you have or ever had the following

Teeth Grinding/Clenching
Pain/Tenderness in Jaw
Bleeding Gum
Bad Breath

For woman only

Take birth control pills
Pregnant
Breast Feeding Special Care

I understand that all my information will be kept strictly confidential in accordance with privacy regulations, and I authorize release as is necessary to provide proper and safe services.

I understand that all my information will be kept strictly confidential in accordance with privacy regulations, and I authorize release as is necessary to provide proper and safe services.

I consent the Dentist and auxiliary staff to perform necessary examination, diagnostic procedures & treatments, as required, to achieve the proper level of dental care; including the performing of dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anesthetic, sedation, x-rays as indicated.

I consent the Dentist and auxiliary staff to perform necessary examination, diagnostic procedures & treatments, as required, to achieve the proper level of dental care; including the performing of dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anesthetic, sedation, x-rays as indicated.

I acknowledge that I would be financially responsible for the Dental services provided regardless of insurance coverage; and, I understand payments are due when services are rendered.

I acknowledge that I would be financially responsible for the Dental services provided regardless of insurance coverage; and, I understand payments are due when services are rendered.

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Credit Card Number

Card Holder Name

Expiry Date

CVV

I understand that the appointment time given to me is reserved for me only; and as a courtesy to time and dedication of Dentist and auxiliary staff, it is my responsibility to inform the office if I need to change or cancel at least 2- business - days before my appointment. I acknowledge that if I fail to do so, I would be responsible to pay a $75 no-show or short-notice cancelation fee with no exception other than for extreme emergencies.

I understand that the appointment time given to me is reserved for me only; and as a courtesy to time and dedication of Dentist and auxiliary staff, it is my responsibility to inform the office if I need to change or cancel at least 2- business - days before my appointment. I acknowledge that if I fail to do so, I would be responsible to pay a $75 no-show or short-notice cancelation fee with no exception other than for extreme emergencies.

I certify that I have read, understood and accurately completed this form to the best of my knowledge and have not knowingly omitted any information. I also acknowledge that it is my full responsibility to inform the office of any changes prior to my upcoming appointment and fill the "Patient Update Form" once in the office.

I certify that I have read, understood and accurately completed this form to the best of my knowledge and have not knowingly omitted any information. I also acknowledge that it is my full responsibility to inform the office of any changes prior to my upcoming appointment and fill the "Patient Update Form" once in the office.

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Patient/ Guardian Full Name

Date

Patient (Guardian) Signature

Emergency Contact

Primary Insurance

Secondary Insurance (if available)

Contact Us

Office Hours