Des Moines Dentist: Leading Dental Office in Des Moines

About You

Today's Date*

Mr. Mrs. Ms. Dr.

First Name*

Middle Name

Last Name*

How would you like our staff to address you?

Male Female

Birthday*

Age

SS#

Home Address*

City*

State*

Zip*

Apt#

Martial Status

Single Married Divorced Separated Widowed

Home Phone*

Cell

Work

Email*

Employer

Employer Address

City

State

Zip

Apt#

How long there?

Occupation

Where & when are best times to reach you?

Whom may we Thank for referring you?

Other family members seen by us

Previous Dentist

Present Dentist

Last Visit Date

Spouse Information

His / Her Name

Employer

Work

Ext.

Social Security#

Birthday

DL#

Person Responsible For Account

Work

Ext.

Home

Billing Address

City

State

Zip

Apt#

Relationship

Social Security#

Employer

DL#

Dental Insurance

Primary Dental Insurance

Insuarance Co. Name

Insurance Co. Address

City

State

Zip

Insurance Co. Phone

Group# (Plan, Local or Policy#)

Insured's name

Relationship

Insured's Birthday

Insured's SS #

Insured's Employer

Insurance Co. Address

City

State

Zip

Secondary Dental Insurance

Insuarance Co. Name

Insurance Co. Address

City

State

Zip

Insurance Co. Phone

Group# (Plan, Local or Policy#)

Insured's name

Relationship

Insured's Birthday

Insured's SS #

Insured's Employer

In the event of an emergency, is there someone who lives near you that we should contact?

His / Her Name

Relationship

Work

Home

Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Are you under a physician's care now?

Yes No

Have you ever been hospitalized or had a major operation?

Yes No

Have you ever had a serious head or neck injury?

Yes No

Are you taking any medications, pills or drugs?

Yes No

Do you take, or have you taken, Phen-Fen or Redux?

Yes No

Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?

Yes No

Are you on a special diet?

Yes No

Do you use tobacco?

Yes No

Do you use controlled substances?

Yes No

Women : Are you

Pregnant/Trying to get pregnant? Nursing? Taking oral contraceptives?

Are you allergic to any of the following?

Aspirin Penicillin Codeine Acrylic Metal Latex Local Anesthetics Other

Do you have, or have you had, any of the following?

AIDS/HIV Positive Alzheimer's Disease Anaphylaxis Anemia Angina Arthritis/Gout Artificial Heart Valve Artificial Joint Asthma Blood Disease Blood Transfusion Breathing Problem Bruise Easily Cancer Chemotherapy

Chest Pains Cold Sores/Fever Blisters Congenital Heart Disorder Convulsions Cortisone Medicine Diabetes Drug Addiction Easily Winded Emphysema Epilepsy or Seizures Excessive Bleeding Excessive Thirst Fainting Spells/Dizziness Frequent Cough Frequent Diarrhea

Frequent Headaches Genital Herpes Glaucoma Hay Fever Heart Attack/Failure Heart Murmur Heart Pace Maker Heart Trouble/Disease Hemophilia Hepatitis A Hepatitis B or C Herpes High Blood Pressure Hives or Rash Hypoglycemia

Irregular Heartbeat Kidney Problems Leukemia Liver Disease Low Blood Pressure Lung Disease Mitral Valve Prolapse Pain in Jaw Joints Parathyroid Disease Psychiatric Care Radiation Treatments Recent Weight Loss Renal Dialysis Rheumatic Fever Rheumatism

Scarlet Fever Shingles Sickle Cell Disease Sinus Trouble Spina Bifida Stomach/Intestinal Disease Stroke Swelling of Limbs Thyroid Disease Tonsillitis Tuberculosis Tumors or Growths Ulcers Venereal Disease Yellow Jaundice

Have you ever had any serious illness not listed above?

Yes No

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.

A 1.5% service charge will be added to all past due balances. I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover.

Signature

Date

Payment is due in full at the time of treatment unless prior arrangements have been approved. Thank you for filling out this form completely. It will enable us to help you more effectively. If you have any questions at any time, please ask us. We are happy to help. Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CBC and the ADA.

FINANCIAL Guidelines

Thank you for choosing our office as your dental health care provider. We are committed to providing you with the highest quality lifetime dental care, so that you may fully attain optimum oral health. Please understand that payment of your bill is considered part of your treatment.

Payment is due at the time service is provided. Our office accepts cash, personal checks, MasterCard, Visa, and Discover. Outside financing is available upon request and approval.

Please check if you would like more information about financing options.

Please Note: Returned checks will be subject to additional fees. In the case it becomes necessary for our office to enlist a collection service and/or legal assistance; you will be responsible for any collection and/or legal charges incurred.

Do You Have Insurance?

As a courtesy to you we will help you process all your insurance claims. Please understand that we will provide an insurance estimate to you, however it is not a guarantee that your insurance will pay exactly as estimated. Your insurance company and your plan benefits ultimately determine the amount paid. We will, of course, do all we can to make sure your estimate is as accurate as possible.
All charges you incur are your responsibility regardless of your insurance coverage. We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your insurance company. Your insurance policy is a contract between you, your employer, and your insurance company. Our office is not a party to that contract.
Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company's arbitrary determination of usual and customary rates.
We ask that you sign this form and/or any other necessary documents that may be required by your insurance company. This form instructs your insurance company to make payment directly to our office.
We ask that you pay the deductible and co -payment, which is the estimated amount not covered by your insurance company, by cash, check, MasterCard, Visa or Discover at the time we provide the service to you.
Insurance payments are ordinarily received within 30-60 days from the time of filing. If your insurance company has not made payment within 60 days, we will ask that you contact your insurance company to make sure payment is expected. If payment is not received or your claim is denied, you will be responsible for paying the full amount at that time.
We will cooperate fully with the regulations and requests of your insurance company that may assist in the claim being paid. Our office will not, however, enter into a dispute with your insurance company over any claim.

We thank you for the opportunity to serve your dental health care needs and welcome any questions you may have concerning your care or our financial policy.

I HAVE READ, UNDERSTAND AND AGREE TO THE ABOVE TERMS AND CONDITIONS. I AUTHORIZE MY INSURANCE COMPANY TO PAY MY DENTAL BENEFITS DIRECTLY TO MY DENTAL OFFICE.

PATIENT Signature (Parent of Child)

Date

Plaza Dental Group

On a scale of 1 - 10, with 10 the highest rating:

How important is your dental health to you?

1 2 3 4 5 6 7 8 9 10

Where would you rate your current dental health?

1 2 3 4 5 6 7 8 9 10

What is the most important thing to you about your future smile and dental health?

What is the most important thing to you about your dental visit today?

If you could change your smile, you would:

Make them brighter Make them straighter Close spaces Have a smile makeover

Replace black metal fillings with natural, tooth-colored fillings Repair chipped teeth Replace missing teeth Replace old crowns that don't match

How many times a day do you brush?

Floss/Week?

When was your last dental cleaning?

Please check any of the following that apply :

Sensitivity (hot, cold, sweet) Tooth pain or discomfort when chewing Headaches, earaches, neck pain Bleeding, swollen or irritated gums Cracked or chipped teeth

Teeth or fillings breaking Grinding or clenching teeth TMJ(Jaw pain) Loose or shifting teeth

If you could whiten your teeth for a cost anyone could afford, would you do it?

Yes No

If you currently have a partial or denture would you be interested in learning about how to make them a permanent and more comfortable solution?

Yes No

Have you ever been told you have sleep apnea? Snore frequently or have trouble sleeping?

Yes No

Do you have any fears of dental visits?

Yes No

New Patient Registration

(The following confidential information is for our records only)

The benefits of a happy, healthy smile are immeasurable! Our goal is to help you reach and maintain maximum oral health. Please fill out this form completely. The better we communicate, the better we can care for you.

About You

Spouse Information

Dental Insurance

Medical History

FINANCIAL Guidelines

I HAVE READ, UNDERSTAND AND AGREE TO THE ABOVE TERMS AND CONDITIONS. I AUTHORIZE MY INSURANCE COMPANY TO PAY MY DENTAL BENEFITS DIRECTLY TO MY DENTAL OFFICE.

Plaza Dental Group

Our Services