Welcome to Glen Valley Dentistry, we appreciate your time in filling out the information below. Please bring printed information with you for your appointment. You can also e mail this page to appointments@gvdentistry.com. You will need to save this page as a .doc then fill in the appropriate fields on your computer then send as an attachment. We will obtain your signature at your appointment. Everything on this form can be selected before printing, except the signatures at the bottom. ~ 4 sheets will print PATIENT INFORMATION Name: Birthdate: Address: Email: Home Phone: Cell Phone: Select appropriate box: Single Married Divorced Separated Spouse or Parent/Guardian Name: Patient or Parent/Guardian Employer's Name: If patient has Healthy Kids please enter Healthy Kids ID # Business Address: Business Phone: Who should we contact in case of emergency? Phone # where to reach them? How did you hear about our office ?
PERSON RESPONSIBLE FOR THIS ACCOUNT Name: Realtionship to patient: Birthdate: Email: Address: Home Phone: Cell # Work # Employer: ID Number Is the responsible person for this account a patient of Glen Valley Dentistry Yes No INSURANCE INFORMATION Name of Insured: Relationship to patient: Birthdate: Work # Insurance Company Name: Insurance ID #
SECONDARY INSURANCE INFORMATION (if applicable) Name of Insured: Relationship to patient: Birthdate: Work # Insurance Company Name: Insurance ID #
MEDICAL INFORMATION
Name Are you under the care of a physician? Yes No Have you ever been hospitalized or had a major operation? Yes No If Yes Please explain Have you ever had a head or neck injury? Yes No Are you taking any medications, pills or drugs? Yes No If yes please list below : Do you take or have you taken, Phen Fen or Redux? Yes No Are you on a special diet? Yes No Do you use tobacco? Yes No Do you use controlled substances? Yes No Are you allergic to any of the following? Aspirin Penicillin Codeine Acrylic Metal Latex Local Anesthetic Other:
Do you have or have had any of the following?
Glaucoma
Cortisone Medicine
Pain in Jaw Joints
*Does condition require premedication (antibiotics) for dental appointment? Yes No Have you ever had any serious illness not listed above? Yes No
Patient Signature (after printed)__________________________________Date Signed_______________
SMILE EVALUATION
Hold a full face mirror 12"-14" from your face. Smile to show your teeth; take the time to observe your teeth carefully. Then answer the following questions. 1. Do you like the appearance of your smile? Yes No
If no, please explain
2. Are your teeth all in alignment (straight?) Yes No
If not, please explain
3. Do you have spaces that you don't like? Yes No If yes, please explain
4. Do you like the color of your teeth? Yes No If not, please explain.
5. Do you like the shape of your teeth? Yes No
If not, please explain 6. Are your teeth...?
Chipped Protruding Hidden
7.Do you like the way your teeth come together? Yes No
8. Are there old fillings or dental work that you don't like looking at? Yes No
If yes, please explain.
What would you like to change the most in the appearance of your teeth?
How would you like your teeth to look?
PRINT NOW AND SIGN BOTH SHEETS PLEASE (unless you are e mailing then you will have opportunity to sign when you come in)
Glen Valley Dentistry 9041 North Rodgers Drive, Caledonia MI 49316 616-891-8931 We recognize the need for a definite understanding between patient and dentist regarding financial arrangements for dental care. Responding to this need we have established the following financial policy. Please take a moment to read through the policy and sign.
To our patients with insurance:
Please remember that your insurance coverage is a contract between you and your insurance company and is not a substitute for payment. We are happy to work with you and your insurance company but you are ultimately responsible for your account. We will gladly bill your insurance company, but your portion is due the day of treatment. Payment is required within 15 days of notification.
To our patients without insurance:
We request that all charges be paid at the time of each visit.
Statement Fee A $3.00 billing fee will be added to your balance if statements are sent out. If the account becomes past due and turned over to collections, you are responsible for the cost of such collection procedures and you and your family will be dismissed from the practice.
Missed Appointment Fee:
If you cannot keep your appointment, please provide at least 24 hours advance notice or you may be charged a cancellation fee.
I/ We understand and agree to the above policy . __________________________ _________________ Signature of Patient or Legal Guardian Date
__________________________ _________________ Signature of Patient or Legal Guardian Date