Park Place Dental Group

Park Place Dental Group 60 Park Place,
1107 Arts Section Newark, NJ 07102

908-925-8110

Welcome

We are pleased to welcome you to . Please take a few minutes to fill out this form as completely as you can. If you have questions , we'll be glad to help you. We look forward to working with you in maintaining your dental health.

Patient Information
Name:
Soc.Sec. # :
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Email:
Sex:
Age:
Birthdate:
Marital Status:
Patient Employed By :
Occupation :
Business Adress :
Business Email :
Business Phone :
Whom may we thank for referring you? :
Notify Incase of Emergency:
Business Phone :
Home Phone :
Cell Phone:
Business Email :

Primary Insurance
Person responsible for this account:
Relation:
Birth Date
Soc.Sec. # :
Address (if different from parents):
City:
State:
Zip:
Cell Phone:
Email:
Home Phone :
Person Responsible Employed by:
Occupation:
Business Email :
Business Phone :
Business Address:
Ins. Company:
Insurance Email :
Phone :
Contact #:
Group #:
Subscriber’s #:
Name(s) of other dependents under this plain:

Additional Insurance
Is Patient covered by additional insurance?
Subscribers Name:
Relation:
Birth Date
Soc.Sec. # :
Address (if different from parents):
City:
State:
Zip:
Cell Phone:
Email:
Home Phone :
Subscriber Employed by:
Business Phone :
Ins. Company:
Insurance Email :
Phone :
Contact #:
Group #:
Subscriber’s #:
Name(s) of other dependents under this plain:
Dental History
What would you like us to do today?
Are you in dental discomfort today?
Former Dentist:
Phone :
Address :
Dentist Email:
Date of Last Dental Care:
Date of last X-rays:

Check Y for yes or N for no if you have or have not had the following:

Bad breath
Sensitivity to sweets
Sensitivity to cold
Food collection between teeth
Bleeding gums
Sensitivity when biting
Periodontal treatment
Grinding or clenching teeth
Clicking or popping jaw
Loose teeth or broken fillings
Sensitivity to hot
Sores or growths in mouth
How often do you brush?
How often do you Floss?
How do you feel about the appearance of your teeth ?
Ever experienced an adverse reaction during or in conjunction with a medical or dental procedure
Medical History

Please answer all questions. Answers to the following questions are for our records only and will be considered confidential.

Physician's name:
Phone :
Business Address:
Physician's Email:
Date of Last Visit:
Have you had any serious illnesses or operations?
If yes, describe
Are you now under the care of a physician?
If yes, describe
Have you ever had a blood transfusion?
If yes, give approximate date(s):
Do you have any Heart Problems?
If yes, Please Describe:
Have you ever taken Fen-Phen/Redux?

For Women Only :

Are you pregnant?
Nursing?
Taking birth control pills?

Check Y for yes or N for no if you have or have not had the following:

AIDS/HIV Positive
Anaphylaxis
Anemia
Arthritis, Rheumatism
Artificial heart valves
Artificial joints
Asthma
Atopic (allergy prone)
Back problems
Blood disease
Cancer
Chemical dependency
Chemotherapy
Circulatory problems
Cortisone treatment
Cough, persisten
Cough, persisten
Diabetes
Epilepsy
Fainting
Food allergies
Glaucoma
Headaches
Heart murmur
Hemophilia/ Abnormal bleeding
Herpes
Hepatitis
High blood pressure
Jaw pain
Kidney disease or malfunction
Liver disease
Material allergies (latex, wool, metal, chemicals)
Mitral valve prolapse
Mitral valve prolapse
Pacemaker/Heart surgery
Psychiatric care
Respiratory disease
Respiratory disease
Rheumatic fever
Scarlet fever
Shingles
Shortness of breath
Skin rash
Spina Bifida
Stroke
Surgical implant
Swelling of feet or ankle
Thyroid disease or malfunction
Tobacco habit
Tonsillitis
Tuberculosis
Ulcer/Colitis
Venereal disease
Bisphophonates
List medications you are currently taking, if any?
List of Allergies, if any:

Authorization

I have reviewed the information on this questionnaire and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate and healthful dental treatment. If there is any change in my medical status, I will inform the dentist.

I authorize my insurance company to pay to the dentist or dental group all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions.

I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance

Signature

Use your mouse cursor or the tip of your finger to sign below

Date:

Payment is due in full at time of treatment unless prior arrangements have been approved

MEDICAL INSURANCE INFORMATION

Primary MEDICAL Insurance Company
Group Number:
ID:
Address :
Name of Insured
Insured SS#:
Insured Employer :
Insured Employer :
Phone Number :
Address :
Patient's Relationship to insured :
Secondary MEDICAL Insurance Company
Group Number:
ID:
Address :
Name of Insured
Insured SS#:
Insured Date of Birth :
Insured Employer :
ID:
Address :
Patient's Relationship to insured :

BROKEN APPOINTMENT POLICY

When a dental appointment is made in our office, a specific me is reserved for the pa ent to see the dentist. The appointment allows the dentist to meet the patient's needs and also schedule other equally important pa ents.

Broken appointments result in a loss of valuable me that could be spent with pa ents in need of treatment and they are very costly to our office. For this reason, if a pa ent fails to keep an office visit he or she will be charged a fee for a broken appointment.

In addi on, because we are not in the position to determine if an excuse is valid or not, no excep ons will be made to this policy.

It is the pa ent's ul mate responsibility to keep their scheduled appointment. If an appointment does need to be cancelled or rescheduled for any reason, please no fy our office with 24 hours in advance of the appointed me, and no broken appointment fee will be charged.

Thank you for your anticipated cooperation.

Patient or Guardian Signature

Use your mouse cursor or the tip of your finger to sign below

Date:

PATIENT LIABILITY STATEMENT

I UNDERSTAND THAT I AM PERSONALLY RESPONSIBLE FOR CHARGES INCURRED FOR SERVICES RENDERED BY Park Place Dental Group IF ANY OF THE FOLLOWING APPLY:

  1. My health plan requires prior authorization before receiving services and I have not obtained such an authorization or I received services in excess of such authorization.
  2. My Dental plan coverage has lapsed or expired at the me I receive services.
  3. I have chosen NOT to use my Dental plan coverage

I ALSO UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CO-PAYMENTS AND CO-INSURANCE SUMS UNDER MY DENTAL PLANS.

I ALSO UNDERSTAND THAT I AM RESPONSIBLE FOR THE BALANCE OF THE BILL THAT IS NOT PAYABLE BY MY INSURANCE PLAN OR SECONDARY PLAN.

FURTHERMORE, I AGREE, THAT IF LEGAL ACTION BECOMES NECESSARY DUE TO MY FAILURE TO PAY MY RESPONSIBILITES, THE COST OF THAT ACTION TOGETHER WITH INTEREST, ALLOWED BY LAW, WILL ALSO BE PAYABLE BY ME.

PRINT PATIENT NAME:
GUARANTOR NAME IF NOT PATIENT:

Signature of Financially Responsible Party

Use your mouse cursor or the tip of your finger to sign below

Date:

NOTICE OF PRIVACY PRACTICES NOTICE and DESIGNATION OF DISCLOSURE

Patient Receipt Acknowledgment

I. Acknowledgment of Privacy Practice Notice

I,

Name:

acknowledge that I have received the Notice of Privacy Practices. I have also been given the opportunity to ask questions about this notice and to request additional restrictions on the Practice's use and disclosure of my Individually Identifiable health Information, or request additional confidential treatment of communications between the Practice and myself or others.

Signature of Patient / Parent / Guardian

Use your mouse cursor or the tip of your finger to sign below

Date:
Witness :
Relationship :

II.I wish to be contacted in the following manner (check all that apply)

Home telephone
If yes, Number
OK to leave a message with detailed information
Leave message with call back number only
Work telephone:
If yes, Number
OK to leave a message with detailed information
Leave message with call back number only
Written communication
OK to mail to my home address
OK to mail to my work / office
OK to fax to this number:
If yes, Number
Other
If yes, describe

III. Designation of certain Relatives, Close Friend and Other Caregivers

I agree that Park Place Dental Group smay disclose certain health information to a family member, close personal friend or other caregiver because such person is involved with my health care or payment relating to my healthcare, In that case, Park Place Dental Group will disclose only information that is directly relevant to the person’s Involvement with my healthcare or payment relating to my healthcare.

I designate the following persons listed below as persons involved with my healthcare or payment relating to my healthcare for the purpose of Park Place Dental Group smaking the limited disclosures described above. I understand that I am not required to list anyone and that I may change this list at any time in writing. I also understand this only valid for one year from the date signed.

Print Name:
Last 4 digits of SSN :
Print Name:
Last 4 digits of SSN:
Print Name:
Last 4 digits of SSN:

Signature of Patient / Parent / Guardian

Use your mouse cursor or the tip of your finger to sign below

Date:

© 2024 - American Dental Software All rights reserved.